2.1.010 Local Agency Nutrition Personnel: Breastfeeding Coordinator

Effective: 10/2025

Issued: 04/1995

Authority references: 2025 7 CFR 246.11(c)(7); USDA FNS WIC Breastfeeding Policy and Guidance (2016), USDA FNS WIC Nutrition Services Standards

Policy:

Each local agency (LA) must have on staff a person designated as the breastfeeding coordinator. The breastfeeding coordinator is responsible for developing and implementing all breastfeeding services provided to participants at the LA. Successful completion of state agency (SA) approved training must occur within the time designated by the SA. Refer to policy 2.4.010.

Procedures:

1. Coordinates all breastfeeding services and education provided to participants.
   1. Assists breastfeeding women with advanced lactation concerns and monitors other professional staff providing this level of support.
   2. Provides technical assistance (TA) to LA staff and other community professionals, educating them on evidence-based breastfeeding practices.
   3. Maintains an inventory of current breastfeeding resources and educational materials.
   4. Works with LA staff to ensure the agency is a supportive breastfeeding environment per LA Responsibility: Supportive Breastfeeding Environment Policy 2.1.020.
   5. Ensures that all LA staff have completed required breastfeeding training within the required time frames.
   6. Ensures all WIC local agency staff know their role in breastfeeding support (Refer to Breastfeeding Roles Chart).
   7. Provides and/or reviews lesson plans for group and individual nutrition education sessions pertaining to breastfeeding.
   8. Evaluates the appropriateness of breastfeeding-related pamphlets, fact sheets and audiovisuals for use in the Missouri WIC program, according to established criteria.
   9. Plans and evaluates breastfeeding interventions implemented by the LA using various health and nutrition data from the SA and other reputable sources.
   10. Manages the LA’s breast pump program.
       1. Maintains the LA inventory of manual, multi-user and single-user electric breast pumps and double pumping kits; purchases additional inventory as the budget allows.
       2. Ensures that the LA has breast pump guidelines and a multiuser electric breast pump loan agreement, per Breast Pump Policy 2.1.030.
       3. Ensures proper tracking of multi-user electric breast pumps and appropriate follow-up with participants to whom the pumps have been loaned.
       4. Ensures all LA staff who provide pumps are trained on when to issue them, proper pump use and cleaning, and appropriate storage and use of breast milk.
2. Required knowledge, skills and abilities:
   1. Working knowledge of the principles and management of lactation.
   2. Knowledge of social, cultural and economic problems impacting breastfeeding promotion and education.
   3. Ability to evaluate breastfeeding education materials for use with individuals and groups.
   4. Ability to collect, interpret, evaluate and use statistical data related to breastfeeding.
   5. Good communication and organization skills.
   6. Ability to establish and maintain effective working relationships with WIC participants, team members and other community partners.
   7. Understanding of breastfeeding program management and promotion.
3. Qualifications:
   1. Education:
      1. Must be a health care professional (i.e., registered nurse (RN), registered dietitian (RD), nutritionist or International Board Certified Lactation Consultant (IBCLC)) or WIC Competent Professional Authority (CPA).
      2. Must have completed an SA-approved course in lactation management or within one year of hire (i.e., the WIC breastfeeding (BF) curriculum levels 1-4 or a Lactation Education Accreditation and Approval Review Committee (LEAARC) recognized 45-hour lactation course) or is an IBCLC. 
      3. Must stay current on breastfeeding information by attending SA approved lactation courses or conferences and reading current breastfeeding resources and research.
   2. Experience:
      1. Minimum of one year of experience in counseling breastfeeding dyads is preferred.
      2. Experience in using critical thinking and problem-solving skills in counseling situations.
      3. Experience in providing training and adult education.
      4. Experience in working in poorly resourced communities.

2.1.020 Breastfeeding Promotion and Support

Effective: 04/2026

Issued: 04/1995

Authority references: 2025 7 CFR 246.11(c)(7)(i); 246.11(c)(7)(iv); 246.11(e)(1); WIC policy memo 92-3; 2016 WIC Breastfeeding Policy and Guidance

Policy:

All local agency (LA) staff are responsible for promoting and supporting exclusive breastfeeding for six months and continued breastfeeding for at least the first year of life and thereafter as long as desired. Breastfeeding for two years or longer is recommended by multiple health organizations.

Procedures:

1. The LAs must ensure that a positive clinic environment is created, which clearly endorses and supports breastfeeding as the biological norm for infant feeding.
   1. Educational materials must be made available to participants, either by hard copy or electronically, that portray breastfeeding as the preferred infant feeding method in a manner that is culturally and aesthetically appropriate.
   2. Breastfeeding promotional materials must be displayed in all rooms where participants receive nutrition/breastfeeding education and in the WIC waiting room. These materials include posters, photos, signs and literature promoting breastfeeding. If services are provided remotely via video, LA staff must also consider the camera’s background view.
   3. LA staff must demonstrate a positive attitude toward breastfeeding and incorporate positive breastfeeding messages into all relevant educational materials, outreach efforts and educational activities for program participants and potential participants.
   4. The visibility of infant formula must be minimized by ensuring that cans of formula are stored out of the participants' view. Formula promotional materials cannot be visible to participants in the clinic. This includes online presence. Social media posts should limit the visibility of infant formula and bottle-feeding content, unless required for an announcement, such as a formula recall.
      1. Formula representatives should not be present in the WIC clinic or provide education to LA staff. LA staff should contact their state agency (SA) nutrition technical assistance (TA) staff for guidance.
      2. Formula coupons may only be given to fully formula-fed infants at the discretion of the nutritionist.
   5. Breastfeeding should be encouraged throughout the WIC clinic, including the WIC waiting room, but an area that is reasonably private should be provided for women who request it.
      1. The reasonably private area should be away from entrances.
      2. Chairs with arms should be available when possible.
2. All pregnant women must be encouraged to breastfeed exclusively unless contraindicated for health reasons.
   1. At certification, professional staff or the breastfeeding peer counselor (BFPC) must initiate a conversation about breastfeeding. The goal of this conversation is to determine the participant’s breastfeeding intentions, address concerns, describe how WIC supports breastfeeding and, if offered, introduce the Breastfeeding Peer Counseling (BFPC) program.
   2. LA staff should inform all pregnant women that their infant’s breastfeeding amount determines their postpartum default food package.
      1. Information about breastfeeding program benefits can be explained either verbally or using a digital, written, printed or another SA-approved tool.
   3. By the end of certification, all pregnant women must be offered nutrition education on breastfeeding, unless contraindicated for health reasons. Refer to policy 2.4.110.
3. Breastfeeding mothers whose infants receive formula must be supported to breastfeed to the maximum extent possible with minimal supplementation of formula.
   1. Formula may be issued to breastfed infants only when requested, and after professional staff have:
      1. Completed a breastfeeding assessment.
      2. Counseled the breastfeeding woman on the effects of formula supplementation on their breast milk production.
4. LAs are encouraged to apply for the BFPC program and subsequently the Breastfeeding Friendly (BFF) WIC Clinic program through the local agency plan (LAP) application in WebGrants. Breastfeeding peer counselors enhance but do not replace the breastfeeding support provided by professional staff or the requirements of WIC breastfeeding policies.
   1. The BFPC program provides LA funding for additional breastfeeding support for participants. LAs that have carried out the BFPC program for at least one year and have implemented the strategies of the BFF WIC Clinic program should apply to be recognized as a BFF WIC Clinic. The BFF WIC Clinic program provides additional funding to continue providing optimal breastfeeding support.

2.1.030 Breast Pump Policy

Authority: PL 101-147, WC-95-37-P, WC-99-36-P

Issued: 01/1996

Revised: 10/2021

Policy:

Local agencies (LAs) may provide manual breast pumps or single-user electric breast pumps, or loan multi-user electric breast pumps to breastfeeding WIC participants for a minimal fee or at no charge. Breast pumps shall not be distributed to participants prenatally and WIC benefits shall not be terminated or suspended for un-reimbursed loss or damage to loaned pumps.

Prior to loaning or providing pumps, each agency shall:

Develop breast pump guidelines that are specific to their agency and a loan agreement, which fully states the participant’s rights and responsibilities.

Have trained, designated staff to implement and manage the program, which includes staff that can provide proper education, documentation, and appropriate required follow-up.

Track, clean, and maintain multi-user electric breast pumps in good working order and maintain an inventory in the Missouri WIC Information Network System (MOWINS.)

Not reuse manual breast pumps, double pumping kits, and single-user electric breast pumps.

Provide the serial number of new multi-user electric breast pumps to the state agency (SA) to be recorded in MOWINS and ensure that the appropriate WIC tag is placed on the breast pump. Contact participants at least monthly to retrieve loaned electric breast pumps that are not returned when requested, and refer to the SA for collection efforts if unsuccessful.

Fees charged for manual breast pumps or double pumping kits cannot be more than the cost of the product and money collected must be used to purchase additional product or to repair multi-user electric breast pumps.

LAs that charge a refundable deposit for loaned breast pumps must ensure that their fees are reasonable (no greater than $50) and do not create a barrier to the participant. The fee must be waived for participants that state they do not have the money to pay the refundable deposit.

Procedure:

1. Developing LA breast pump guidelines and loan agreement
   1. Prior to providing manual breast pumps, single-user electric breast pumps or loaning of multi-user electric breast pumps develop written guidelines, specific to your agency. (See Sample Agency Breast Pump Loan Guidelines.  
   2. Prior to loaning multi-user electric breast pumps develop a loan agreement that includes sufficient information to attempt to recover the pump. 
2. Maintaining a breast pump inventory
   1. Provide the serial number of new multi-user electric breast pumps to the SA to be recorded in MOWINS and ensure that the appropriate WIC tag is placed on the breast pump.
   2. Track all multi-user electric breast pumps in MOWINS by issuing the pump to the participant and keep the inventory up-to-date at all times. Use the “Breast Pump Report” Crystal Report to monitor the location of issued pumps.
   3. Store all breast pumps in a secure location and in an area that is not easily accessible to WIC participants.
3. Determining need and type of breast pump
   1. Decide which type of breast pump should be given, manual or electric, by completing a proper assessment of the participant’s need, which would include evaluating the reason for the pump, how often they may need to pump, and where the pump will be used. 
   2. Verify that the participant did not receive a pump kit in the hospital or received one that is not designed to work with the type of breast pump being provided, and then provide a double pump kit, if necessary.
4. Issuing breast pumps
   1. Provide appropriate training on the assembly, use, and cleaning of the breast pump and storage of human milk, prior to providing a pump.
   2. When providing manual breast pumps, single-user electric breast pumps, or loaning multi-user electric breast pumps, document in the participant file in MOWINS the item that was given, or loaned, to the participant and the reason the pump is needed.
   3. Issue multi-user electric breast pumps to the participant in MOWINS.
      1. Under the “Participant Activities” tab, click on “Breastfeeding.”
      2. Select the “Issue Breastfeeding Items” option, then “Add.”
      3. Click on the drop down and select the type of pump to be loaned.
      4. Search for the pump by entering the WIC tag number, then a space, then the pump serial number. Select the pump and click “OK.”
      5. Have the participant sign for the pump, or have a staff person sign in lieu of the participant if needed.
   4. When loaning a multi-user electric breast pump, have the participant read, initial each statement, and sign the breast pump loan agreement and keep all loan agreements in a central file.
   5. Determine the food issuance cycle after assessing the need for follow-up of the participant.
5. Follow-up/Support
   1. Have an appropriate staff member (i.e., International Board Certified Lactation Consultant (IBCLC), nutritionist, Competent Professional Authority (CPA), breastfeeding coordinator, or peer counselor) contact participants who have been loaned an electric breast pump.
   2. Document follow-up in the breastfeeding notes of MOWINS.
6. Retrieving multi-user electric breast pumps
   1. When the participant reports that they are no longer using the pump, or when the family is no longer participating in WIC, the pump should be returned. Contact the participant by telephone at least monthly to attempt to recover the pump and, if unsuccessful, mail a certified letter to the participant. Document these attempts in MOWINS or in the central pump file.
   2. If the participant is unable to be contacted by telephone or mail, a lost/stolen report may be filed with the local authorities, if that option was included on the signed Breast Pump Loan Agreement.
   3. If all attempts to retrieve the pump have failed, complete the Missing or Damaged Multi-User Electric Breast Pump Report and submit it to the SA.
   4. Notify the SA if the pump is returned to the LA after collection efforts have begun.
7. Cleaning and maintaining multi-user electric breast pumps
   1. Upon receipt of a returned pump, immediately visually check for the return of all parts and assess the pump for any damage.
   2. Clean the pump motor casing and carrying case with sanitizing solution according to the manufacturer’s recommendations and check for any pest infestation. Agencies may isolate returned pumps in a clear plastic bag or bin for three (3) days before cleaning to check for any pests.
8. If single-user electric breast pumps are provided to breastfeeding mothers, the following criteria must be used for distribution and the participant must sign the Personal Double Pump Questionnaire/Agreement:
   1. Participant must demonstrate a need for the pump.
   2. Mother must be separated from her infant at least 32 hours per week.
   3. Mother must be planning to offer breast milk exclusively to her infant and committed to continued long-term exclusive breastfeeding.
   4. Infant must be receiving no formula from WIC.
   5. Pump cannot be provided to the mother before four (4) weeks postpartum. If a mother needs a pump before then, she may be loaned a multi-user electric breast pump.

Guidelines:

1. LAs may choose from the following options for breast pump loan guidelines:
   1. Manual and single-user electric breast pumps and double pumping kits may be provided to WIC participants at no charge, or a fee may be charged for the cost or a portion of the cost, but the money collected must be used to purchase additional products or to repair multi-user electric breast pumps.
   2. LAs may charge a refundable deposit for electric breast pumps that are loaned as long as the money collected is used to maintain and replace breast pumps. LAs need to ensure that their fees are reasonable (no greater than $50) and do not create a barrier to the participant. The fee must be waived for participants who state they do not have the money to pay the refundable deposit.
   3. Manual breast pumps, single-user pumps, double pumping kits, and any soft carrier issued with the pump shall not be returned to the agency or reused. These items do not need to be issued under the “Issue Breastfeeding Items” tab in MOWINS.
   4. LAs may report missing multi-user pumps to local authorities, if it is clearly outlined in their guidelines and the pump loan agreement.
2. LAs should verify if the participant has already received an appropriate breast pump through MO HealthNet (Medicaid) or private insurance. If the participant already has an appropriate pump, or is eligible to receive one, education can then be provided to ensure the pump is used correctly and notification given that no pump will need to be provided through WIC.
3. Before loaning multi-user electric breast pumps each LA must have a loan agreement that outlines the responsibility of the participant and the following may be included:
   1. Be subject to a financial penalty if the pump is not returned.
   2. Maintain monthly contact with the LA.
   3. Notify the LA immediately if there is a change to their name, address, and/or telephone number.
   4. Use the electric breast pump and kit according to the instructions for assembly, use, and cleaning.
   5. Keep the electric breast pump in their possession.
   6. Should include a release of liability of the LA, Missouri Department of Health and Senior Services, health department, etc.
   7. Return the electric breast pump in clean condition by the due date, or earlier if requested, or immediately under any of the following circumstances:
      1. The pump becomes damaged or ineffective.
      2. They are no longer in need of the pump.
      3. They are no longer receiving WIC services.
      4. They transfer to another agency.
4. Consider the following staff competencies when assessing the appropriate staff to distribute breast pumps and educate mothers:
   1. The ability to assess a woman’s need for a breast pump and select the appropriate pump that meets her need.
   2. The ability to teach a woman how to use, clean, and care for a pump.
   3. The ability to teach hand expression.
   4. The ability to provide appropriate breastfeeding assistance, counseling, and follow-up services.
   5. The ability to develop a pumping plan (frequency, location, length of pumping sessions, etc.) with the mother.
   6. Examples of appropriate staff are an IBCLC, nutritionist, CPA, breastfeeding coordinator, or peer counselor.
5. LAs should consider a triage system for distribution of electric breast pumps, if need exceeds supply. The nutritionist or appropriate trained staff person shall determine the need for an electric breast pump, which may include and is not limited to (in order of priority):
   1. Premature or hospitalized infant or mother
   2. Infants with feeding or latching problems
   3. Low milk supply
   4. Mother of multiple infants
   5. Temporary breastfeeding problems such as engorgement and medication contraindicated for breastfeeding
   6. Mother returning to work or school
6. Appropriate trained staff members shall contact participants who have been provided an electric breast pump to give appropriate follow-up and education.
   1. Participants should be contacted by phone:
      1. Within 24-48 hours to ensure that the pump is operating correctly and that the mother is using it properly.
      2. Every 2-3 days until an adequate milk supply is achieved or participant indicates assistance is no longer needed.
      3. Every 2-3 weeks for a sick or hospitalized infant to support mothers in maintaining an adequate milk supply.
   2. Agencies may consider placing participants who have been loaned an electric breast pump on a benefit issuance cycle of one (1) month to insure the mother is receiving proper follow-up.
7. Documenting the provision of a pump to a participant facilitates communication with other WIC staff and protects the LA from liability issues. Appropriate documentation would include:
   1. The reason for issuing the pump and the type of pump provided.
   2. The mother’s commitment to continue breastfeeding.
   3. A summary of the counseling and education provided, including the pumping plan (frequency, location, length of pumping sessions, etc.)
   4. Plans to follow up with the participant.
8. The following guidelines are recommended for the storage of breast milk.
   1. Store in a refrigerator at a temperature of 40 degrees F or below and use within 4 days.
   2. Store in the freezer (freezer door separate from refrigerator) with a temperature of 0 degrees F or below and use within 6 months.
   3. Thaw (from frozen) in a refrigerator with a temperature of 40 degrees or below and use within 24 hours.
   4. Storage recommendations may differ for mothers collecting milk for hospitalized infants. LA staff should defer to the hospital’s storage protocols.

2.1.040 Local Agency Nutrition Personnel: WIC Designated Breastfeeding Expert

Effective: 10/2025

Issued: 06/2023

Authority references: 2025 7 CFR 246.3, Breastfeeding Policy and Guidance (July 2016), Appendix A (Definitions), H

Policy:

Each local agency (LA) participating in the breastfeeding peer counseling (BFPC) program must have on staff a person or persons qualified as a WIC designated breastfeeding expert (DBE). LAs not participating in the BFPC program may have DBEs. The DBE is an individual with special experience or training who provides breastfeeding expertise and care for more complex breastfeeding problems when WIC staff face situations outside their scope of practice. Successful completion of state-approved training must occur within the timeframes designated by the SA. Refer to policy 2.4.010.

Procedures:

1. The WIC DBE’s responsibilities include, but are not limited to, the following:
   1. Provides follow-up breastfeeding support to participants.
   2. Acts on all referrals from other WIC staff regarding complex breastfeeding situations beyond their scope of practice.
   3. Assesses and counsels mothers and infants with complex breastfeeding situations.
   4. Communicates care plans to the WIC team as appropriate.
   5. Refers parents to health care providers for further assessment and care when needed.
   6. Provides lactation training for WIC staff under the direction of the LA breastfeeding coordinator.
   7. Promotes human milk feeding in the community under the direction of the LA breastfeeding coordinator.
   8. Maintains lactation credentials and certifications and acquires ongoing continuing education to stay current with lactation management research and practice.
   9. Operates within the Scope of Practice for the WIC Designated Breastfeeding Expert as defined within the Food and Nutrition Services (FNS) competency-based training platform and the Breastfeeding Roles Chart per 2.1.010 LA Nutrition Personnel: Breastfeeding Coordinator.
2. Required knowledge, skills and abilities:
   1. Working knowledge of the principles and management of lactation.
   2. Good communication and counseling skills.
   3. Ability to establish and maintain effective working relationships with WIC participants, WIC team members and other community partners.
   4. Literacy, language and computer communication skills appropriate to meet the needs of a diverse population.
3. Qualifications:
   1. Education:
      1. Must be a health care professional (i.e., registered nurse (RN), registered dietitian (RD), nutritionist or International Board Certified Lactation Consultant (IBCLC)) or WIC Competent Professional Authority (CPA). The IBCLC is the preferred WIC DBE (2013 WIC Nutrition Services Standards).
      2. Successful completion of the FNS competency-based training for WIC Breastfeeding Curriculum (Levels 1-4) (Breastfeeding Basics and Breastfeeding: Beyond the Basics) OR a State-approved competency-based breastfeeding training that is consistent with the FNS WIC Breastfeeding Curriculum (Levels 1- 4) (Level 1 45-hour course or other approved 45-hour course).
      3. Must stay current on breastfeeding information by attending SA-approved lactation courses or conferences and reading current breastfeeding resources and research.
      4. The best practice is for the DBE to receive 75 hours of continuing education in lactation every five years. At a minimum, the DBE must meet the continuing education requirement for their role in WIC per policy 2.4.010 or for their lactation certification.
4. Experience:
   1. A minimum of one year of experience in counseling breastfeeding dyads is preferred.
   2. Experience in using critical thinking and problem-solving skills in counseling situations.
   3. Experience in providing training and adult education.
   4. Experience in working in poorly resourced communities.

2.2.010 Local Agency Personnel: Breastfeeding Peer Counselor

Effective: 10/2025

Issued: 10/2005

Authority references: WC-04-19-I; WC-05-17-I

Policy:

The local agency (LA) may use a breastfeeding peer counselor (BFPC) as a paraprofessional to give basic breastfeeding information, support and encouragement to pregnant and breastfeeding women and serve as a role model for breastfeeding women. Successful completion of state agency (SA) approved training must occur within the time designated by the SA. Refer to policy 2.4.010.

Procedures:

1. Specific duties may vary based on the LA’s plan.
   1. Counsel pregnant women and breastfeeding mothers by telephone, teleconference, home visits, hospital visits and in the WIC clinic at scheduled intervals determined by the LA. This contact does not count as nutritional education. Refer to policy 2.4.110.
   2. Assist or teach prenatal breastfeeding classes with an approved lesson plan by the BFPC coordinator and organize breastfeeding mother support groups. Refer to policy 2.4.110.
   3. Receive a caseload of WIC participants and make contact with the participants based on the LA's contact schedule. Refer to Contacting WIC Mothers in the BFPC Training Manual.
   4. Provide information and support for women, including the benefits of breastfeeding, overcoming common barriers and getting a good start with breastfeeding. Assists in managing common maternal and infant breastfeeding concerns.
   5. Contact the BFPC coordinator or the LA designated breastfeeding expert when a situation is outside their scope of practice or guidance is needed. Refer to policy 2.2.060.
   6. Remain available to new mothers with breastfeeding problems who need assistance outside the usual 8 a.m. to 5 p.m. working hours.
   7. Respect each participant by keeping their information strictly confidential. Refer to policy 8.1.010. Peer counselors must sign the LA confidentiality statement at the time of hire.
   8. Keep accurate records of all contacts made with WIC participants using the Management Information System (MIS). When the MIS is unavailable, peer counselors will document the contact on the logs provided by the state and transfer the information to the MIS as soon as possible (no later than the end of the month). Peer counselors must protect the logs and keep them confidential when working outside the clinic.
   9. Attend monthly staff meetings and peer counseling meetings as appropriate.
   10. Read assigned books and materials on breastfeeding provided by the supervisor.
   11. Assist LA staff in promoting breastfeeding through special projects and duties as assigned.
   12. Separate role duties if working in the LA in another paraprofessional role. Hours must be scheduled separately for each role.
       1. Time spent in alternate roles must not be charged to peer counseling grants.
       2. Peer counselors should be scheduled to perform only peer counseling duties for a full shift. At a minimum, peer counselors must be scheduled to perform peer counseling duties for at least half the shift and may be scheduled to fill another role the other half of the shift, as long as the two time periods are clearly separated by a lunch break. The peer counselor cannot switch her time between the two roles as desired.
2. Qualifications:
   1. Paraprofessionals recruited and hired from the target WIC population.
      1. A paraprofessional is an individual without extended professional training in health, nutrition or the clinical management of breastfeeding. Paraprofessionals complete specific tasks within a defined scope of practice. They assist professionals but are not licensed or credentialed as health care, nutrition or lactation professionals.
      2. Peer counselors cannot be members of the WIC professional staff, such as a nutritionist, competent professional authority (CPA), designated breastfeeding expert (DBE), WIC coordinator, BF coordinator or BFPC coordinator.
         1. If a peer counselor attains a credential or degree while employed as a BFPC, the credential or degree may not be used or advertised in the peer counseling role or other lactation roles in the LA. The LA should prepare for the BFPC to transition to a professional role once the credential or degree is obtained.
         2. For information on how BFPCs may transition to the CPA role, refer to section D. 1. b of policy 2.4.050.
   2. Previous or current breastfeeding experience.
   3. Basic communication skills.
   4. Enthusiastic attitude about breastfeeding and desire to help other mothers enjoy a positive experience.
   5. Similar background to WIC participants served in the clinic, including age, language and culture.
   6. Current or previous WIC participation (preferred but not mandatory).
   7. Available to work the hours required to meet the LA’s plan for peer counseling.
   8. Available to answer after-hours calls and texts using a telephone, softphone or texting service provided by the LA.
   9. High school diploma or equivalency (i.e., GED/HiSET).
3. Training requirements:
   1. Participates in state-approved training programs for peer counselors.
   2. Attends additional educational opportunities, such as informal training sessions or observes other peer counselors or lactation consultants helping mothers when available.
   3. Attends conferences or workshops on breastfeeding as determined by the LA.

2.2.020 Local Agency Personnel: Breastfeeding Peer Counselor Program Coordinator

Effective: 10/2025

Issued: 10/2005

Authority references: USDA WIC Breastfeeding Model Components for Peer Counseling; USDA FNS WIC Nutrition Services Standards (2013); USDA FNS WIC Breastfeeding Policy and Guidance (2016); USDA Allowable Costs for Breastfeeding Peer Counseling Programs

Policy:

The local agency (LA) must have a breastfeeding peer counselor (BFPC) program coordinator to manage the WIC BFPC Program at the LA, train and provide mentorship for BFPCs and report on BFPC program activities to the state agency (SA). Successful completion of state-approved training must occur within the timeframes designated by the SA. Refer to policy 2.4.010.

Procedures:

1. Roles and duties of the BFPC program coordinator:
   1. Conduct an annual needs assessment to identify gaps in breastfeeding resources and services within the local agency and community that the WIC peer counseling program can address.
   2. Develop goals and objectives for the LA's peer counseling program.
   3. Oversee the planning, management, implementation and evaluation of LA peer counseling activities.
   4. Implement policies and procedures designated by the SA for the BFPC program.
   5. Determine peer counseling staffing needs.
   6. Recruit and interview potential peer counselors in alignment with program policies and standards.
   7. Ensure peer counselors receive the required training and supervision to be successful.
      1. Provide orientation to new peer counselors immediately upon hire and address LA policies and procedures.
      2. Ensure that the peer counselor attends required state-sponsored training.
      3. Provide local training and in-services as needed.
      4. Hold individual meetings with peer counselors at least monthly and include them in WIC staff meetings as applicable.
      5. Provide ongoing supervision and feedback for peer counselors.
      6. Conduct monthly observation and chart review for each peer counselor during the first six months of employment, and review at least three charts and conduct one observation annually thereafter. If a supervisor or BFPC coordinator determines that a peer counselor needs additional coaching, the number of spot checks should be increased to facilitate coaching.
      7. Discuss future training and career goals with BFPCs. Provide mentorship to BFPCs who have the aptitude and desire to pursue a professional career path with Missouri WIC.
   8. Ensure that BFPCs keep all information obtained from WIC participants confidential in all work settings. Refer to policy 8.1.010.
   9. Collect and review documentation of records and data from peer counselors to prepare the BFPC Activity Report.
   10. Submit the BFPC Activity Report to the SA BFPC coordinator on a quarterly basis.
   11. Consult with SA breastfeeding staff to assess for ongoing improvements to the program that may be needed.
   12. Inform the SA BFPC coordinator of any changes to the peer counseling program, including staff changes or concerns.
2. Required knowledge, skills and abilities:
   1. Working knowledge of the principles and management of lactation.
   2. Knowledge of social, cultural and economic problems impacting breastfeeding promotion and education.
   3. Ability to collect, interpret, evaluate and use statistical data related to breastfeeding.
   4. Good communication and organizational skills.
   5. Ability to establish and maintain effective working relationships with WIC participants, team members and other community partners.
   6. Understanding of breastfeeding program management and promotion.
3. Qualifications:
   1. Education:
      1. Must be a health care professional (i.e., registered nurse (RN), registered dietitian (RD), nutritionist or International Board Certified Lactation Consultant (IBCLC)) or WIC Competent Professional Authority (CPA).
      2. Must have completed an SA-approved course in lactation management or within one year of hire (i.e., the WIC breastfeeding (BF) curriculum levels 1-4 or a Lactation Education Accreditation and Approval Review Committee (LEAARC) recognized 45-hour lactation course) or is an IBCLC.
      3. Must stay current on breastfeeding information by attending SA approved lactation courses or conferences, and reading current breastfeeding resources and research.
   2. Experience:
      1. Minimum of one year of experience in program management or supervision is preferred.
      2. Experience in using critical thinking and problem-solving skills in counseling situations.
      3. Experience in providing training and adult education.
      4. Experience in working in poorly resourced communities.

2.2.030 Local Agency Personnel: Senior Breastfeeding Peer Counselor

Effective: 10/2025

Issued: 10/2005

Authority references: WC-04-19-I; WC-05-17-I

Policy:

The local agency (LA) may use a senior breastfeeding peer counselor (BFPC) to perform the BFPC role per policy 2.2.010 as well as maintain a supervisory role over other peer counselors. Successful completion of state agency (SA) approved training must occur within the time designated by the SA. Refer to policy 2.4.010.

Procedures:

1. Specific duties may vary based on the LA’s plan.
   1. Counsel pregnant women and breastfeeding mothers by telephone, teleconference, home visits, hospital visits and in the WIC clinic at scheduled intervals determined by the LA. This contact does not count as nutritional education. Refer to policy 2.4.110.
   2. Assist or teach prenatal breastfeeding classes with an approved lesson plan by the BFPC coordinator and organize breastfeeding mother support groups. Refer to policy 2.4.110.
   3. Receive a caseload of WIC participants and make contact with the participants based on the LA's contact schedule. Refer to Contacting WIC Mothers in the BFPC Training Manual.
   4. Provide information and support for women, including the benefits of breastfeeding, overcoming common barriers and getting a good start with breastfeeding. Assists in managing common maternal and infant breastfeeding concerns.
   5. Contact the BFPC coordinator or the LA lactation expert when a situation outside their scope of practice or guidance is needed. Refer to policy 2.2.060.
   6. Remain available to new mothers with breastfeeding problems who need assistance outside the usual 8 a.m. to 5 p.m. working hours.
   7. Respect each participant by keeping their information strictly confidential. Refer to policy 8.1.010. Peer counselors must sign the LA confidentiality statement at the time of hire.
   8. Keep accurate records of all contacts made with WIC participants using the Management Information System (MIS). When the MIS is unavailable, peer counselors will document the contact on the logs provided by the state and transfer the information to the MIS as soon as possible (no later than the end of the month). Peer counselors must protect the logs and keep them confidential when working outside the clinic.
   9. Attend monthly staff meetings and peer counseling meetings as appropriate.
   10. Read assigned books and materials on breastfeeding provided by the supervisor.
   11. Assist LA staff in promoting breastfeeding through special projects and duties as assigned.
   12. Separate role duties if working in the LA in another paraprofessional role. Hours must be scheduled separately for each role.
       1. Time spent in alternate roles must not be charged to peer counseling grants.
       2. Peer counselors should be scheduled to perform only peer counseling duties for a full shift. At a minimum, peer counselors must be scheduled to perform peer counseling duties for at least half the shift and may be scheduled to fill another role the other half of the shift, as long as the two time periods are clearly separated by a lunch break. The peer counselor cannot switch her time between the two roles as desired.
2. Supervisory duties may vary based on the LA’s plan. Senior Breastfeeding Peer Counselor may:
   1. Recruit and interview potential peer counselors in alignment with program policies and standards.
   2. Train and mentor new and less experienced peer counselors while operating within their scope of practice.
   3. Provide ongoing supervision to other peer counselors.
   4. Complete monthly contacts on the BFPC Activity Report. The BFPC Coordinator must complete the quarterly narrative on the BFPC Activity Report.
3. Qualifications:
   1. Paraprofessionals recruited and hired from the target WIC population.
      1. A paraprofessional is an individual without extended professional training in health, nutrition or the clinical management of breastfeeding. Paraprofessionals complete specific tasks within a defined scope of practice. They assist professionals but are not licensed or credentialed as health care, nutrition or lactation professionals.
      2. Peer counselors cannot be members of the WIC professional staff, such as a nutritionist, competent professional authority (CPA), designated breastfeeding expert (DBE), WIC coordinator, BF coordinator or BFPC coordinator.
         1. If a peer counselor attains a credential or degree while employed as a BFPC, the credential or degree may not be used or advertised in the peer counseling role or other lactation roles in the LA. The LA should prepare for the BFPC to transition to a professional role once the credential or degree is obtained.
         2. For information on how BFPCs may transition to the CPA role, refer to section D. 1. b of policy 2.4.050.
   2. Previous or current breastfeeding experience.
   3. Exemplary performance as a peer counselor and completion of all basic peer counselor training. A minimum of two years of experience as a peer counselor is suggested before promotion to senior breastfeeding peer counselor.
   4. Supervisory and leadership skills.
   5. Successful completion of an advanced course in lactation management.
   6. Enthusiastic attitude about breastfeeding and desire to help other mothers enjoy a positive experience.
   7. Similar background to WIC participants served in the clinic, including age, language and culture.
   8. Current or previous WIC participation is preferred but not mandatory.
   9. Available to work the hours required to meet the LA’s plan for peer counseling.
   10. Available to answer after-hours calls and texts using the telephone, softphone or texting service provided by the LA.
   11. High school diploma or equivalency (i.e., GED/HiSET).
4. Training requirements:
   1. Participates in state-approved training programs for peer counselors.
   2. Attends additional educational opportunities, such as informal training sessions or observes other peer counselors or lactation consultants helping mothers when available.
   3. Attends conferences or workshops on breastfeeding as determined by the LA.

2.2.040 Compensation of Peer Counselors

Authority: WC-04-19-I, WC-05-17-I

Issued: 10/2005

Revised: 07/2009

Policy:

LAs may hire peer counselors as salaried employees or on a contractual basis (hourly or part-time contracts) and shall pay the peer counselor for their services and costs incurred while providing services as suggested by the SA.

Procedures:

1. LAs may hire peer counselors as salaried employees or contractual basis (hourly or parttime contracts) based upon the agency's policies.
   1. Contractual employees are paid based on the jobs they complete. When hiring peer counselors as part-time contractors, the following are to be considered:
      1. Assign duties within clear parameters of the job assignment.
      2. Document performance.
      3. Monitor performance frequently.
      4. Provide a standard time-keeping system.
2. LA shall pay peer counselors to compensate for their services and costs used for providing services. All compensation must be monetary. No gift certificates, as a form of compensation, are allowed. The following are guidelines:
   1. Use the same general hourly part-time rate typical of other entry level positions such as WIC clerical positions or pay more based on experience and credentials to aid with retention is recommended.
   2. Reimburse mileage for home and hospital visits and long-distance telephone charges while peer counselors are providing services as requested by peer counselors.
   3. Reimburse costs for conducting group education sessions in the WIC clinic.
   4. Provide office supplies or reimburse cost for office supplies.
   5. Reimburse for registration and travel expenses for breastfeeding workshops and conferences as appropriate.

2.2.050 Documentation of Participant Contacts

Authority: WC-04-19-01, WC-05-17-I

Issued: 10/2005

Revised: 10/2021

Policy:

The local agency (LA) Breastfeeding Peer Counseling (BFPC) Program Coordinator shall instruct peer counselors to document contacts in the Missouri WIC Information Network System (MOWINS).

Procedures:

1. The local BFPC program coordinator shall:
   1. Explain the purpose of documentation to peer counselors during the orientation.
   2. Instruct peer counselors to:
      1. Use MOWINS to document all contacts with prenatal and breastfeeding women including the type of contact, education provided, and referrals made.
      2. Require peer counselors to document contacts in MOWINS using one of the following methods:
         1. Create a breastfeeding note; or
         2. Complete the ‘Breastfeeding Peer Counseling Contacts’ function
      3. When making contacts outside of the clinic, peer counselors may document on the Prenatal [BROKEN LINK] or Postpartum [BROKEN LINK] contact logs provided by the state agency and transfer the information to MOWINS as soon as possible (no later than the end of the month). Peer counselors using notes documentation shall include “later entry for (date)” in a breastfeeding note to indicate notes entered after the day of contact.
   3. Submit the BFPC Activity Report [BROKEN LINK] by the 11th of the month following the previous quarter. The report shall be submitted to the Missouri BFPC program coordinator, via email, as an Excel document and shall include activity for the previous quarter. Agencies may use the BFPC Weekly Worksheet [BROKEN LINK] to assist in tracking activities contained in the BFPC Activity Report.
2. The local BFPC program coordinator shall review peer counselor contact documentation on a regular basis to ensure the notes are complete, accurate, contain appropriate content and wording, and include only abbreviations listed in the Health and Nutrition Assessment Handbook (HNAH [BROKEN LINK]).
3. The state BFPC program coordinator or state monitoring staff shall monitor randomly selected participant contact information in MOWINS.

2.2.060 Referrals of Breastfeeding Participants

Authority: WC-04-19-I; WC-05-17-I

Issued: 10/2005

Revised: 07/2009

Policy:

The local agency (LA) shall instruct peer counselors about the limitations of their services, circumstances for referrals, and documentation procedures.

Procedures:

1. The LA breastfeeding peer counseling (BFPC) program coordinator shall:
   1. Assist peer counselors in referring a mother to a health care professional or community lactation expert when they express concerns about their infant's health or when the peer counselor suspects illness or unusual behavior.
   2. Provide materials on available referrals and information on hotline numbers for a variety of social service needs.
   3. Instruct on documentation procedures using the Missouri WIC Information Network System (MOWINS.)
2. The LA BFPC program coordinator shall ensure that the peer counselor will contact them, the agency nutritionist or lactation expert in the following circumstances. (Refer How to Help Mothers with Breastfeeding Concerns in the Breastfeeding Peer Counselor Manual):
   1. The mother has delivered a premature or sick infant and is unable to begin breastfeeding following delivery.
   2. The infant is having difficulty latching on to the breast after several attempts and the mother has begun bottle-feeding.
   3. Infant has a nursing strike that lasts longer than 24 hours.
   4. The mother has decided to breastfeed, but her infant has been bottle-feeding since birth.
   5. The mother wants to breastfeed, but has been advised to discontinue or delay initiation in the hospital or after discharge by her health care provider.
   6. The mother wants to breastfeed and has a history of substance abuse or has a partner who is abusing drugs.
   7. The mother is breast and bottle-feeding her infant who is less than one month old.
   8. The mother is experiencing engorgement and comfort measures do not relieve the engorgement after 24 hours.
   9. Mother has been discharged from the hospital and reports fever or flu-like symptoms.
   10. The mother has breast tenderness or redness on one breast.
   11. The infant is having less than six wet diapers within a 24-hour period and the mother is nursing her infant at least eight times within a 24-hour period.
   12. The mother has sore nipples, which have not been resolved within 24 hours by following common comfort measures.
   13. The mother has cracked, bleeding or blistered nipples.
   14. The mother has a chronic disease such as diabetes or epilepsy or any illness or condition requiring medications.
   15. Mother is concerned about milk supply after simple measures have been tried.
   16. Mother is concerned about excessive crying of her baby after calming techniques do not help.
   17. Whenever the counselor is unsure about any situation and needs information and/or feedback about an interaction with a participant.

2.2.070 Breastfeeding Peer Counseling Social Media

Authority:

Issued: 10/2013

Revised:

Policy:

Local WIC agencies may use social media (Facebook, Twitter, MySpace, YouTube, etc.) to provide evidence based breastfeeding information and to promote WIC services and breastfeeding peer counseling. Social media sites facilitated by peer counselors must be monitored by the Breastfeeding Peer Counselor Coordinator or other designated professional staff to ensure all content is appropriate and evidenced based. Peer counselors shall not use their personal social media accounts to represent their local WIC agency or Breastfeeding Peer Counseling Program.

Procedures:

1. Social media networks shall be used for:
   1. Promoting WIC services.
   2. Inviting participants to prenatal breastfeeding classes or support groups.
   3. Advertising breastfeeding promotion events.
   4. Promoting the fully breastfeeding food package.
   5. Providing evidence-based breastfeeding information and resources.
   6. Helping new mothers connect with peer counselors.
2. Breastfeeding peer counselors shall be responsible for what they write and the messages conveyed to WIC participants.
   1. LA staff, including peer counselors, must follow policy 8.1.010 and shall not post any WIC participant information.
   2. Only LA address or phone numbers shall be provided through social media. Peer counselors shall not provide personal information, such as home address or phone number.
   3. LA social media sites shall only be used for WIC-related business.
   4. All breastfeeding information and website links posted on a social media site shall be evidenced-based and in line with information provided by the state WIC program and provided in the breastfeeding peer counseling training.
   5. The BFPC coordinator or another other designated professional staff member must monitor all information posted through social media and have full access to the account.
   6. All information posted on social media shall be culturally sensitive and professional. Items or information related to religion or politics shall not be posted.
   7. Disparaging remarks about an individual or healthcare provider will not be tolerated and can result in termination of a peer counselor or loss of Breastfeeding Peer Counseling funding.
   8. Social media sites must include “This institution is an equal opportunity provider and employer” statement.
   9. The LA Facebook page must include a disclaimer that advice from other moms should never replace the advice from medical experts. If they have questions or concerns about their health or the baby’s well-being they should always contact their physician or a lactation consultant.
   10. Social media shall not be used to advertise or promote specific product brands.
   11. Peer counselors shall not counsel moms or answer detailed breastfeeding questions through social media. Peer counselors should ask when they can contact the participant by phone or invite the participant into the WIC clinic to discuss in more detail.
   12. Peer counselors shall not use their personal social media accounts to represent their local WIC agency or Breastfeeding Peer Counseling Program.
   13. It is the responsibility of the BFPC Program Coordinator that peer counselors who are representing their LA through social media have read and understands the social media policy and consequences for not following the policy.

Guidelines:

1. Considerations when using Facebook
   1. A “Facebook Page” can be set up for anyone to “like” to provide information to a large number of people. If this page cannot be monitored frequently throughout the day, it is not recommended to allow the public to make posts.
   2. A “Facebook Group” can be set up for a small number of people which will allow for more interaction and discussion. Groups are not recommended if local WIC agency personnel are not available to monitor discussions. Participation should be by invitation and a participant should not be made a member without their knowledge.
2. Peer counselors should be encouraged to not “Friend” participants on their personal Facebook page. In small communities it may be difficult to prevent, but peer counselors should be cautious in becoming a Facebook “Friend” with a participant.
3. When posting messages consider the following:
   1. Experts suggest that posts are viewed more during the week than on weekends. Fridays have the least number of views.
   2. Post often to keep audience engaged, but not too often. It is recommended to not post more than 1 to 2 times per day. Quality of posts is more important than quantity.
   3. Keep messages short and simple.
   4. Use acronyms that everyone understands or spell out acronyms that could cause confusion.
4. Promote your social media sites
   1. Provide links through your local WIC agency web page.
   2. Provide information on referral lists and other handouts.
   3. Promote in your clinic with signs and word of mouth.

2.2.080 Local Agency Cell Phone Usage

Authority: Loving Support Model for Successful Peer Counseling Programs

Issued: 01/2015

Revised:

Policy:

A local agency (LA) may provide a cell phone to their peer counselor(s) for use in making participant contacts for the Breastfeeding Peer Counseling (BFPC) Program. The LA shall ensure that the peer counselor is aware of expectations associated with the phone and shall provide monitoring and oversight to ensure appropriate use and participant confidentiality.

Procedures:

1. Providing a cell phone enhances breastfeeding services to participants by making peer counselors available outside of normal clinic hours and will give them the flexibility to provide breastfeeding support from locations other than the WIC clinic.
   1. If a LA allows the peer counselor to provide breastfeeding support beyond normal clinic hours, it is recommended she be provided a cell phone instead of using her personal phone for the following reasons:
      1. Prevents participant contact information from being stored in personal cell phone. If the peer counselor leaves her position, the agency would still have access to the information.
      2. Prevents participants from contacting a peer counselor that is no longer employed and prevents having to provide a new phone number to participants.
      3. If the peer counselor is not available to take after hours breastfeeding support calls, the phone can be given to another peer counselor or WIC staff member.
   2. The LA shall be responsible for all costs associated with the cell phone and will be reimbursed by invoicing appropriate charges on either BFPC Special Funding 1 or 2. Prior approval either through the LA Plan (LAP) or directly from the BFPC Program Coordinator is required.
   3. The LA shall ensure that a peer counselor using an LA owned cell phone understands the expectations associated with using it. LAs may request the peer counselor(s) to sign a usage agreement (see sample [BROKEN LINK]).
2. The LA shall ensure that a cell phone issued to a peer counselor is used appropriately by monitoring usage on a regular basis. The following information shall be discussed with the peer counselor:
   1. The device and any accessories provided shall remain the property of the LA.
   2. The peer counselor shall have no expectations of privacy in the use of an LA issued cell phone.
   3. The peer counselor shall only allow authorized personnel to use the cell phone issued by the WIC agency.
   4. The cell phone shall be used only to contact WIC participants and to conduct business related to WIC.
   5. The peer counselor shall not use the phone for any reason while operating a motor vehicle.
   6. Reasonable precautions, including a device/screen lock and secure passwords, shall be used to prevent theft, vandalism, or unauthorized access to client information.
      1. In the event that a device is lost, stolen, or vandalized due to the peer counselor’s failure to use reasonable precautions, the LA may require the peer counselor responsible for the cell phone to reimburse them for reasonable costs to replace the device.
      2. Failure to maintain and use a secure password for the phone may result in breach of confidentiality and corresponding disciplinary action may be taken against the employee.
      3. The LA shall notify the district technical assistance team and the BFPC Program Coordinator of a possible breach of confidentiality, if the phone is lost or stolen.
   7. If contacts are maintained on the device, the peer counselor shall review the contacts list, at least monthly, to purge information for participants who are no longer breastfeeding, who have transferred out of the agency, or those whose contact information is no longer valid.
   8. If a peer counselor anticipates she will be unable to respond to participants outside normal WIC clinic hours as expected, she must notify her supervisor as soon as possible so that alternate arrangements can be made.
   9. Peer counselors must document contacts made by a cell phone in the “Peer Counselor Contacts” function of MOWINS.
3. The LA should purchase a phone that is compatible with the activities and needs of the BFPC program.
   1. When purchasing a phone for peer counselors, the LA should consider the service area and signal range as well as the location the peer counselor will be making calls from.
   2. It is recommended that the LA consider expected use of the phone, including texting and social media when determining the type of phone and services to purchase.

2.3.010 WIC Approved Food List

Authority: Federal Register/Vol. 79, No. 42/Tuesday, March 4, 2014/Rules and Regulations 2015; 7 CFR246.10(b)(1)(2)

Issued: 01/1981

Revised: 08/2015

Policy:

Foods provided through the Missouri WIC Program must be from the current Missouri WIC Approved Food List (#640).

Guidelines:

1. Missouri WIC Approved Food Lists
   1. The authorized foods are listed in the Missouri WIC Approved Food List (#640) at the following link.
   2. Participants or their caregiver must receive the Missouri WIC Approved Food List at the initial visit (Initial Nutrition Education) to use it when they redeem WIC food instruments.
   3. “Store brands” means that brands can be the store’s own brand or a brand name carried by the store that was created by the wholesaler which supplies the store.
   4. Food Selection Criteria policy 2.3.110 is used to develop the Missouri WIC Approved Food List.

2.3.020 Food Packages for Infants

Effective: 04/2026

Issued: 01/1981

Authority references: 2025 7 CFR 246.10

Policy:

All infants from birth through 11 months of age must have the appropriate default food package for their age and breastfeeding amount assigned in the Management Information System (MIS). The competent professional authority (CPA) or nutritionist (i.e., professional staff) must then individually tailor the default food package as necessary and appropriate, based on the WIC nutrition and breastfeeding assessment (i.e., nutrition assessment).

Refer to policy 2.3.030 for additional tailoring options only available to infants with a qualifying condition under Food Package 3, and the required medical documentation (i.e., WIC-27).

The local agency (LA) must issue an appropriate food package on the day a participant is declared eligible for program benefits. Breastfeeding infants eligible for the program but not receiving supplemental foods are exceptions. LA staff must refer to the Food Reference Guide.

All WIC staff are responsible for promoting and supporting exclusive breastfeeding for six months and continued breastfeeding for at least the first year of life and thereafter as long as desired. Refer to policy 2.1.020.

A mother’s food package (FP) is determined by her infant’s breastfeeding amount. Refer to the table below. The infant and mother should have a two-way link established in the MIS.

The following tables show the default FPs for infants that will be assigned in the MIS based on breastfeeding amount and age. Formula quantities are based on the primary contract infant formula. Some and mostly breastfeeding infants’ default FPs will automatically populate with the minimum formula amounts for their age.

Default FPs 1 and 2 (fully breastfeeding):

Default FPs 1 and 2 (mostly breastfeeding):

Default FPs 1 and 2 (some breastfeeding):

Default FPs 1 and 2 (nonbreastfeeding):

Procedures:

1. The primary contract infant formula must be issued as the default formula for infants.
   1. Professional staff must instruct the authorized or alternate representative to:
      1. Follow the manufacturer’s instructions for mixing and storing the formula.
      2. Purchase only one can of the formula initially to determine tolerance and acceptance.
      3. Avoid purchasing dented, expired or close-to-expiring formula.
         1. Defective, spoiled or expired WIC formula may be exchanged for an identical item at the retailer where purchased.
2. Tailoring of the default food packages is completed by the professional staff. LA professional staff must refer to the Formula Reference Guide [BROKEN LINK] when issuing and tailoring formulas.
   1. When the primary contract infant formula is not appropriate based on the nutrition assessment, professional staff must tailor the food package to include other standard contract infant formulas as appropriate. LA staff may contact the on-duty nutritionist for guidance.
      1. Standard non-contract infant formulas may only be issued with a WIC-27. For WIC-27 requirements, refer to policy 2.3.030.
   2. Formula may be issued to breastfed infants only when requested. Refer to policy 2.1.020.
      1. Professional staff must tailor all formula amounts for some and mostly breastfed infants based on the nutrition assessment.
      2. All breastfeeding women must be supported to breastfeed to the maximum extent possible with minimal supplementation of infant formula.
   3. Powder formula should be issued due to its longer shelf life to minimize waste, but a participant may choose liquid concentrate if preferred.
      1. Ready-to-feed (RTF) formula may only be issued for the following reasons.
         1. The participant’s household has an unsanitary or restricted water supply or poor refrigeration.
         2. The person caring for the participant has difficulty correctly diluting concentrated or powder forms.
         3. The formula is only available in RTF.
      2. WIC professional staff should provide education on how to store and minimize waste of liquid concentrate and RTF formulas.
3. Documentation.
   1. Any variation from the default food package must be documented appropriately in the MIS when the food package is assigned.
   2. Depending on the reason and appointment type, a full or abbreviated assessment must be completed and documented in either a subjective, objective, assessment and plan (SOAP) note or a general note. Refer to the summary table below.

      1. Tailoring documentation summary:
         
          

         Tailoring reasons	Certification or mid-certification assessment (MCA) appointments1	Follow-up or benefit load appointments
         Medical condition or special dietary need	Full assessment. SOAP note.	Full assessment. SOAP note.
         Cultural or personal preference	Full assessment. SOAP note.	Abbreviated assessment. General note.

         ¹Recurring tailoring, regardless of the reason, must be documented at MCA and subsequent certifications.

2.3.030 Food Package III

Effective: 12/2024

Issued: 01/1981

Authority references: 2024 7 CFR 246.10; Federal Register/Vol. 89, No. 76/Thursday, April 18, 2024/Rules and Regulations

Policy:

Food package III is for issuance to women, infant and child participants who have a documented qualifying condition that requires the use of a WIC formula (i.e., infant formula, exempt infant formula or WIC-eligible nutritional) because the use of conventional foods is precluded, restricted or inadequate to address their special nutritional needs.

The qualifying conditions include but are not limited to premature birth, low birth weight, failure to thrive, inborn errors of metabolism and metabolic disorders, gastrointestinal disorders, malabsorption syndromes, immune system disorders, severe food allergies that require an elemental formula and life-threatening disorders, diseases and medical conditions that impair ingestion, digestion, absorption or utilization of nutrients that could adversely affect the participant’s nutrition status.

This food package is not authorized for participants whose only condition is a diagnosed food or formula intolerance or food allergy (e.g., lactose, sucrose, milk protein, soy protein) that does not require the use of an exempt infant formula, or solely to enhance nutrient intake or manage body weight without an underlying qualifying condition.

Medical documentation (i.e., a WIC-27 form) is required by a licensed health care provider (HCP) with prescriptive authority, and approval may be given for a maximum of six months.

The local agency (LA) shall issue an appropriate food package the day a participant is declared eligible for program benefits.

The following table shows the default food package issued for each category in the MIS. Each food package shall be individually tailored based on the WIC-27 and the nutrition and breastfeeding assessment.

Default Food Package III

*Cash value benefit. Values may be updated annually for inflation.

Procedures:

1. The LA shall refer to the Formula Reference Guide to determine the WIC staff authorized to approve the prescribed formula.
2. Professional staff determines the primary payer and coordinates services when needed.
   1. MO HealthNet is the primary payer for exempt infant formulas and WICeligible nutritionals that are authorized or could be authorized for reimbursement under MO HealthNet.
   2. When another entity does not provide reimbursement, the state agency (SA) is responsible for providing up to the maximum monthly allowance (MMA) of the WIC formula under Food Package III.
      1. Refer to section D of the Formula Reference Guide for the MMAs for formulas for all WIC categories.
   3. Private insurance, MO HealthNet or the Department of Health and Senior Services (DHSS) Metabolic Formula program must be the primary payer for individuals with metabolic conditions. If the participant does not have private medical insurance, the DHSS Metabolic Formula program is the primary payer. The professional staff shall contact the SA for approval of the metabolic formula for two months while awaiting approval from the DHSS Metabolic Formula Program.
3. The LA shall obtain a completed state medical documentation form (WIC-27) from a licensed HCP with prescriptive authority for all formulas requested with a qualifying condition. Providers with prescriptive authority include physicians, physician assistants or advanced practice nurses (including nurse practitioners or certified nurse specialists).
   1. The HCP shall provide the following:
      1. The qualifying condition.
      2. The name of the authorized WIC formula prescribed. Refer HCPs to the MO WIC Approved Formulas and WIC-Eligible Nutritionals.
      3. The amount needed per day. If the amount prescribed exceeds the MMA, the formula shall be issued in whole containers as close to the MMA without exceeding it.
      4. Mixing instructions if the calorie per fluid ounce concentration differs from the label.
      5. The authorized supplemental foods appropriate for the qualifying condition and their prescribed amounts. To assist the HCP, the professional staff may complete section C of the WIC-27 for supplemental food (i.e., not formula) before the HCP’s approval.
      6. The length of time the WIC formula and supplemental food are prescribed. The maximum approval length is six months.
         1. The approval length is determined by adding the number of months requested to the month that the WIC-27 was signed by the HCP, as long as the participant category does not change during that period.
         2. The approval period will always end on the last day of the final month (e.g., a WIC-27 signed on Aug. 5, for three months, will be approved through Nov. 30).
      7. Documentation of one of the following reasons on the WIC-27 and in the MIS is required if a ready-to-feed (RTF) formula is prescribed. Refer to section B.2.c of policy 2.3.020 for additional circumstances when RTF may be authorized.
         1. The RTF formula better accommodates the participant’s condition.
         2. The RTF formula improves the participant’s compliance with consuming the prescribed WIC formula.
      8. The signature, date and contact information of the HCP with prescriptive authority.
   2. The professional staff shall complete Section E. WIC Use Only in its entirety and scan the WIC-27 into the MIS.
   3. When a WIC-27 is received incomplete or requires clarification, the professional staff may accept verbal orders from the HCP if the prescribed formula is listed and the HCP has signed and dated the form.
      1. The professional staff must document the missing information or clarification on the WIC-27, initial and date each change and record the HCP's name and credentials. If the original form is unavailable, print the scanned WIC-27 and rescan it after it is completed. A new WIC-27 is not required. The participant’s formula shall be issued according to their food benefit cycle.
      2. If the HCP’s signature or the date is missing, issue one month of formula and obtain a new WIC-27 within 1-2 weeks.
   4. The initial medical request may be provided by telephone to the professional staff when absolutely necessary. A signed, completed WIC27 must be received from the HCP within 1-2 weeks.
      1. Document all required information on the WIC-27 and write “verbal order” in the space for the physician’s signature.
      2. Scan the WIC-27 into the MIS.
      3. Issue only one month of benefits.
   5. In instances where the request cannot be approved, the professional staff shall:
      1. Contact the HCP and explain the following as applicable:
         1. The WIC participant’s primary payment source is private medical insurance or the DHSS Metabolic Formula program.
         2. The prescribed supplemental food, formula or WIC-eligible nutritional is not approved for the Missouri WIC program or the participant’s category.
      2. Request the HCP to prescribe an alternate WIC-approved formula or supplemental food.
         1. Follow the procedures above in section C.3 regarding a WIC-27 that requires clarification.
         2. If the HCP refuses to consider an alternate formula or food, contact the SA nutritionist to discuss options.
   6. The professional staff may approve the following substitutions to Food Package III on the WIC-27 as requested by the HCP.
      1. Infants, 6 through 11 months of age, whose medical condition prevents them from consuming supplemental infant foods (i.e., cereal, fruits, vegetables and meat) may receive infant formula or exempt formula at the same MMA as infants 4 through 5 months of age.
      2. Children may substitute:
         1. 32 ounces of infant cereal for 36 ounces of adult cereal.
         2. 144 ounces of infant fruits and vegetables for $26 CVB.
      3. Women may substitute:
         1. 32 ounces of infant cereal for 36 ounces of adult cereal.
         2. 160 ounces of infant fruit and vegetables for $47 CVB (pregnant and postpartum) or $52 CVB (mostly breastfeeding).
      4. Whole milk may be issued to children 24 through 59 months of age and women with a formula or WIC-eligible nutritional also prescribed.
4. Nutrition tailoring is the process of modifying an individual food package to better meet the supplemental nutritional needs of each participant and entails making substitutions, reductions and eliminations to food types and physical food forms to accommodate special dietary needs, cultural practices and personal preferences.
   1. Full provision of age and categorically appropriate supplemental foods shall be issued unless otherwise indicated on the WIC-27 to be omitted by the HCP.
   2. Food Package III shall be tailored first and foremost based on the WIC-27, as well as the nutrition and breastfeeding assessment.
      1. Any tailoring that would contradict the WIC-27 requires consultation with the HCP who initially signed it.
   3. Tailoring for special dietary needs shall be accompanied by a nutrition and breastfeeding assessment and documented in a subjective, objective, assessment and plan (SOAP) note in the MIS.
   4. An abbreviated assessment may be warranted for food package tailoring requests due to cultural practices or participant preference. If not at certification or mid-certification assessment (MCA), these tailoring requests may be documented in a general note.
5. For a participant transferring from another state receiving an exempt formula or WIC-eligible nutritional from that state’s WIC program, refer to section A.1. Transfer In (Receiving Agency) of policy 8.1.160.
6. The LA shall ensure the formula is available through a contracted retailer by having the professional staff contact the stores or pharmacies. If no formula can be provided at a local contracted retailer, the LA must contact the SA to arrange for direct distribution. Refer to policy 2.3.130 for information on the direct distribution procedure.
7. Re-evaluate the participant’s condition during the last month of the approval period. If the participant still requires Food Package III, obtain a new WIC-27 from the HCP.

2.3.040 Food Package IV for Children

Effective: 12/2024

Issued: 01/1981

Authority references: 2024 7 CFR 246.10; Federal Register/Vol. 89, No. 76/Thursday, April 18, 2024/Rules and Regulations

Policy:

Food Package IV shall be issued to children 1 through 4 years of age who do not have a condition qualifying them to receive Food Package III.

The local agency (LA) shall issue an appropriate food package the day a participant is declared eligible for program benefits.

The following table shows the default food package issued for children in the MIS. Each food package shall be individually tailored based on the nutrition and breastfeeding assessment.

*Cash-value benefit. Values may be updated annually for inflation.

Procedures:

1. Issuance of cow’s milk.
   1. Children 12 through 23 months of age shall be issued whole milk in their default food package.
   2. Children 24 through 59 months of age shall be issued skim through one percent milk in their default food package.
   3. Participants may choose between fluid, dry or buttermilk at the store.
2. Issuance of mature legumes and peanut butter.
   1. Participants may choose one of the following options at the store:
      1. A one-pound bag of dry beans.
      2. Four (15-16 oz) cans of beans.
      3. One (16-18 oz) jar of peanut butter.
3. Tailoring the food package.
   1. Nutrition tailoring is the process of modifying an individual food package to better meet the supplemental nutritional needs of each participant and entails making substitutions, reductions and eliminations to food types and physical food forms to accommodate special dietary needs, cultural practices and personal preferences.
      1. Tailoring for special dietary needs shall be accompanied by a nutrition and breastfeeding assessment and documented in a subjective, objective, assessment and plan (SOAP) note in the MIS.
      2. An abbreviated assessment may be warranted for food package tailoring requests due to cultural practices or participant preference. If not at certification or mid-certification assessment (MCA), these tailoring requests may be documented in a general note.
   2. The following milk substitutes may be issued without consulting the health care provider (HCP). Substitutes listed below, C.2.a-d, shall be issued in the same fat variety as the milk included in the child’s default food package. Refer to section D.1-4 of the Food Reference Guide for all cow’s milk substitution rules and rates.
      1. Lactose-free cow’s milk.
      2. Evaporated cow’s milk.
      3. Goat’s milk (evaporated or powder).
      4. Yogurt.
      5. Cheese.
      6. Soy-based beverages.
      7. Tofu.
      8. Two percent milk shall only be issued for the following reasons:
         1. Children 12 through 23 months of age for whom overweight or obesity is a concern (i.e., risk factors 113, 114, and 115).
         2. Children 24 through 59 months of age who are underweight (i.e., risk factors 103 and 134).

2.3.050 Food Packages V, VI and VII for Women

Effective: 12/2024

Issued: 01/1981

Authority references: 2024 7 CFR 246.10; Federal Register/Vol. 89, No. 76/Thursday, April 18, 2024/Rules and Regulations

Policy:

Food Packages V, VI and VII shall be issued to women participants who do not have a condition qualifying them to receive Food Package III.

The breastfeeding assessment and the mother's plans for breastfeeding serve as the basis for determining a woman’s default food package.

Partially breastfeeding women will no longer receive a food package after six months postpartum when they request more than the MMA of formula allowed for a partially (i.e., mostly) breastfed infant. They will continue to be counted as WIC participants and are eligible for nutrition education, breastfeeding promotion and support and referrals to health services.

The local agency (LA) shall issue an appropriate food package the day a participant is declared eligible for program benefits.

The following tables show the default food packages issued for women based on their category and breastfeeding amount in the MIS. Each food package shall be individually tailored based on the nutrition and breastfeeding assessment.

Default Food Packages V, VI and VII for Women

*Cash-value benefit. Values may be updated annually for inflation.

Default Food Package VII x 1.5

*Cash-value benefit. Values may be updated annually for inflation.

Procedures:

1. Issuance of cow’s milk.
   1. All women shall be issued skim through one percent milk in the default food package.
   2. Participants may choose between fluid, dry or buttermilk at the store.
2. Issuance of mature legumes and peanut butter.
   1. Mature legumes and peanut butter options may be chosen by the participant at the store.
   2. Food Packages V and VII include the choice of two, Food Package VI may only choose one, and Food Package VII x 1.5 includes the choice of three of the following options:
      1. A one-pound bag of dry beans.
      2. Four (15-16 oz) cans of beans.
      3. One (16-18 oz) jar of peanut butter.
3. Tailoring the food package.
   1. Nutrition tailoring is the process of modifying an individual food package to better meet the supplemental nutritional needs of each participant and entails making substitutions, reductions and eliminations to food types and physical food forms to accommodate special dietary needs, cultural practices and personal preferences.
      1. Tailoring for special dietary needs shall be accompanied by a nutrition and breastfeeding assessment and documented in a subjective, objective, assessment and plan (SOAP) note in the MIS.
      2. An abbreviated assessment may be warranted for food package tailoring requests due to cultural practices or participant preference. If not at certification or mid-certification assessment (MCA), these tailoring requests may be documented in a general note.
   2. The following milk substitutes may be issued without consulting the health care provider (HCP). Substitutes listed below, C.2.a-d, shall be issued in the same fat variety as the milk included in the woman’s default food package. Refer to section D.1-4 of the Food Reference Guide for all cow’s milk substitution rules and rates.
      1. Lactose-free cow’s milk.
      2. Evaporated cow’s milk.
      3. Powdered goat’s milk.
      4. Yogurt.
      5. Cheese.
      6. Soy-based beverages.
      7. Tofu.
      8. Two percent milk shall only be issued to women for the following reasons:
         1. Underweight (i.e., risk factor 101).
         2. Low maternal weight gain or weight loss during pregnancy (i.e., risk factors 131 and 136).

2.3.060 Guidelines for Food Issuance: Homeless Women, Infants and Children

Authority: 2007 CFR 246.10; Federal Register/ December 6, 2007/Rules and Regulations

Issued: 05/1989

Revised: 10/2009

Policy:

The WIC homeless food package is to be provided to WIC participants who are homeless, displaced or migrant or who have limited access to a stove, refrigerator or water.

Procedures:

1. For all participants or household, the CPA must determine the following prior to issuing the food package:
   1. Availability of refrigeration for foods and prepared formula.
   2. Availability of cooking facilities.
   3. Availability of utensils for eating.
   4. Availability of the number and size of bottles for infant formula.
   5. Availability of bottle washing and sterilization facilities.
   6. The guardian's competence in preparing and storing formula.
   7. The amount of food the participant can safely store during the week.
2. Based on the data obtained in A above, tailor the food package as necessary.
3. For infants, encourage breastfeeding, because it is the easiest and safest way to feed the infant. The CPA shall counsel on the following:
   1. The health benefits of breastfeeding for the mother and her infant, including the reduced risk of illness for her infant.
   2. Breastfeeding will prevent food poisoning and other illnesses caused by having an unsafe or restricted water supply or inadequate refrigeration.
   3. Mothers can re-establish breastfeeding even if they have stopped breastfeeding. Provide support or refer to a lactation consultant, as soon as possible, women who wish to re-lactate.
4. If the guardian chooses to feed infant formula, issue formula according to the WIC Food and Formula Reference Guide based on the following: Issue quantities according to policy 2.3.020.
   1. Issue liquid concentrate or powder infant formula when adequate refrigeration and safe water supply are available.
   2. Issue powder infant formula when no refrigeration is available and a safe water supply is available. The CPA shall explain proper preparation of formula and instruct the guardian to prepare only one bottle of formula at a time.
   3. Issue ready-to-use (feed) when there is an unsanitary or restricted water supply. Refer to policy 2.3.020 for instructions for issuing ready-to-use (feed) formula. Instruct the guardian to discard all formula remaining in the bottle at the end of each feeding.
   4. Issue the appropriate amount of infant cereal and jars of infant food according to 2.3.020.
      1. If refrigeration is not available for leftover foods, instruct the caregiver to discard any leftover infant food.
   5. Educate the parent/guardian on the need to continue introducing solid foods and decreasing the use of formula accordingly.
5. Milk Issuance
   1. If refrigeration is unavailable, issue powder milk
   2. If the participant has been diagnosed as lactose intolerant the CPA shall assess what foods the participant can tolerate and tailor the food package with the appropriate substitutions. Refer to 2.3.040 and 2.3.050 (Guidelines for Issuing Food Package to Children and Women, respectively.)
   3. If water in is not available issue ultra high treatment UHT milk. Check availability of UHT milk at vendors in the area.
6. Juice Issuance
   1. If there is an unsafe or restricted water supply, issue only single strength juice.
7. Egg Issuance
   1. If refrigeration is available, issue up to two-dozen eggs.
   2. If refrigeration is unavailable, issue an additional 64 ounces of canned beans or 18 ounces of peanut butter for 1 dozen of eggs.
   3. Providing additional canned beans or peanut butter as a substitute for eggs may significantly increase the amount of beans/peanut butter the participant can tolerate. The CPA shall assess if the participant could reasonably consume this amount in a month's time.
8. The CPA shall counsel the participant/guardian on the following:
   1. The proper/safe storage of food.
   2. Emphasize that the food is only for the participant to whom it is issued.
   3. The nutrition content of the food provided and the importance of good nutrition. Education should be provided on what foods to add to ensure the diet is nutritionally complete
9. The CPA shall tailor the food package under the Food Prescription tab in MOWINS and document nutrition education provided by selecting the appropriate topics(s) under the Nutrition Education tab.

2.3.070 Prorated Food Packages

Authority: 2019 7 CFR 246.10(c), 246.12 (u)(1)

Issued: 05/1987

Revised: 06/2020

Policy:

This policy provides guidance to Missouri WIC Information Network Systems (MOWINS) proration of food packages for infants, women, and children.

Procedures:

1. MOWINS will calculate the number of days between the actual first-date-to-use and the last-date-to-use for the current food benefits being issued when determining prorated food packages.

   1. For women and children, the following chart shows the start date of a prorated package (Pkg) depending on the number of days in the month for milk, juice, and formula:

      # of Days in Month	Start Date of 3/4 Pkg	Start Date of 1/2 Pkg	Start Date of 1/4 Pkg
      28	5th	13th	21st
      29	6th	14th	22nd
      30	7th	15th	23rd
      31	8th	16th	24th

   2. For infants, the following chart shows the start date of a prorated package depending on the number of days in the month for baby food and formula:

      # of Days in Month	Start Date of 3/4 Pkg	Start Date of 1/2 Pkg
      28	13th	21st
      29	14th	22nd
      30	15th	23rd
      31	16th	24th

   3. Other approved supplemental foods will be issued based on the participant's category. Refer to policies 2.3.020, 2.3.040, and 2.3.050.
2. The CPA shall ensure that the participant is not receiving an excess of the maximum monthly allowance of supplemental food and can override proration of the food benefits to issue a full food package based on the following reason(s):
   1. The participant reported concerns with childcare, chronic family illness, travel distance due to rural residence, transportation, or parent/guardian work schedule.
   2. Local agency (LA) emergency or disaster resulting in delayed benefit issuance.
   3. The reason for the override of the system proration must be documented in MOWINS.
3. The LA will manually prorate formula that is returned by the participant using the following guidance:
   1. See A. 1 and 2 above for the amount of formula to issue.
   2. Proration is determined from the day the participant is present in the clinic requesting formula.
4. Prorated packages can be tailored by the CPA or changed for participant preference. Refer to policies 2.3.020, 2.3.040, and 2.3.050.

2.3.080 Donation or Disposal of Returned Formula

Effective: 11/2025

Issued: 02/1989

Authority references: USDA WIC Food Package Policy and Guidance, March 2018, Chapter 6; WIC Policy Memorandum #2020-1: Donation of Unused, Returned Infant Formula

Policy:

The local agency (LA) must accept the return of all unused standard infant formula, exempt formula and WIC-eligible nutritionals issued by the Missouri WIC program. The LA cannot accept any formulas that are not listed in the current Formula Reference Guide. The state agency (SA) recommends that LAs donate returned formula and WIC-eligible nutritionals in good condition to a facility that accepts donated items, such as food banks, doctors’ offices, hospitals or local health agencies. LAs must maintain inventory control and store formulas according to manufacturer guidelines until they can be donated. The Bill Emerson Good Samaritan Food Donation Act protects donors from liability when donating food in apparently good condition and good faith. The LA may dispose of any returned formula instead of donating it.

Procedures:

1. Returned formula.
   1. Any returned formula cannot be reissued. The LA must either donate or dispose of it.
   2. The LA must store all formulas securely, out of the participant's sight and according to the manufacturer’s guidelines.
   3. All returned formulas must be stored separately from those for direct distribution until donation or disposal is completed.
   4. All direct distribution formulas that have never left the LA’s possession cannot be donated. For direct distribution formula procedures, refer to policy 2.3.130.
2. Donation of formula.
   1. LAs must verify the condition and expiration date of any unused, returned formula cans.
      1. Returned standard infant formula can be donated to food banks, hospitals, doctors’ offices and other institutions that accept it.
      2. Returned exempt infant formula and WIC-eligible nutritionals must be donated to organizations with physician supervision present.
      3. If the items are opened, expired or unfit for human consumption, they may be donated to an animal shelter or veterinary office if accepted.
   2. The LA must obtain receipts for all transactions with organizations that accept donated formula. If an organization does not provide a receipt, LAs may use the following form for documentation: Receipt of Donated WIC Formula and WIC-Eligible Nutritionals (WIC-15).
3. Disposal of formula.
   1. The disposal procedures below must be followed for all returned formulas that are not donated.
      1. Empty the formula container before throwing it away.
         1. Pour concentrate or ready-to-feed formula down the drain.
         2. Open containers and mix powder formula with other trash.
      2. Dispose of the formula in small batches to avoid large amounts in the trash.
      3. Implement practices that ensure no one is removing formula from the trash for consumption.
4. Documentation.
   1. The acceptance of all returned formula and the donation or disposal of it must be documented on a tracking log that includes all of the following information:
      1. Participant’s State WIC Identification Number (SWID).
      2. Formula name.Formula quantity.
      3. Date received.
      4. Initials of staff receiving formula.
      5. Action taken (e.g., donation or disposal).
      6. Quantity (e.g., number of cans, cases or packs).
      7. Date of action.
      8. Name of organization accepting donated formula.
      9. Staff initials. Two staff members must initial to verify the action taken to maximize program integrity.
   2. The LA may use their own tracking log if it includes all necessary information listed above, or one of the following options provided by the SA:
      1. The WIC Formula Log.
      2. The Returned Formula report via the Crystal Reports BI Portal.
   3. The LA must document the following information as a general note in the participant’s file in the Management Information System (MIS):
      1. The name of the formula.
      2. The quantity returned (and replaced, if appropriate).
      3. The reason for the return.
5. Replacement of formula.
   1. The competent professional authority (CPA) or nutritionist (i.e., professional staff) may replace returned formula due to intolerance or a health care provider’s recommendation.
      1. Any formula from an expired benefit period cannot be replaced.
   2. The professional staff must determine the remaining formula benefits to issue without exceeding the maximum monthly allowances for the participant’s feeding category.
      1. LA staff must refer to the Formula Reference Guide to calculate the correct amount of replacement formula to issue. LA staff may contact the SA nutritionist on duty if assistance is needed.
      2. The amount must be prorated appropriately according to policy 2.3.070.
         1. Any overissuance is the LA’s financial responsibility, and the SA reserves the right to bill the LA for it.
   3. The professional staff must issue the remaining benefits in the MIS.

2.3.090 Primary Contract Infant Formula

Authority: CFR 246.16

Issued: 10/2002

Revised: 10/2005

Policy:

The state agency (SA) shall develop and use the single-supplier competitive system to solicit sealed bids from infant formula manufacturers to supply and provide a rebate for primary contract infant formulas. The primary milk-based contract infant formula will be used to determine all other contract brand formulas (e.g., soy-based), which will be issued in the Missouri WIC Program.

Procedures:

1. The SA uses a single-supplier competitive system with the single solicitation system to award a winning bidder.
2. The SA solicits sealed bids no later than 6 months prior to the expiration date of the existing contract.
3. The SA will require the winning bidder to provide both milk-based and soy-based infant formulas. If the winning bidder does not produce a soy-based formula, the bidder must subcontract with another manufacturer to supply the soy-based infant formula and must pay a rebate on the soy-based infant formula supplied by the subcontractor. Bidders must specify the brand name of the milk-based infant formula for which the rebate is being specified.
4. The SA's bid solicitation will require the winning bidder to supply and provide a rebate on all infant formulas it produces that the SA chooses to issue:
   1. The SA will choose which of the winning bidder's other infant formulas, in addition to the primary contract infant formula, will be an approved contract formula.
   2. Rebates must be paid on any new primary contract infant formulas that are introduced after the contract is awarded.
   3. The choice to issue new primary contract infant formulas is solely at the discretion of the SA.
5. The SA's bid solicitation will require bidders to specify a rebate amount for each of the types, sizes, and physical forms of infant formulas listed below:
   1. Types of infant formulas must be a milk-based infant formula, which will be designated as the primary contract infant formula.
   2. Physical forms of infant formulas must be powdered, concentrated liquid, and ready-to-use.
   3. Sizes must be specified for each physical form.
6. All primary contract infant formulas must meet the following requirements:
   1. Must be nutritionally complete, not requiring the addition of any ingredients other than water prior to being served in a liquid state.
   2. Must contain at least 10 milligrams of iron per liter at standard dilution and supply 67 kilocalories per 100 milliliters (i.e., approximately 20 kilocalories per fluid ounce of infant formula) at standard dilution.
   3. Must be approved by FDA.
   4. Must be determined WIC eligible by USDA.
   5. Must be suitable for routine issuance to the majority of generally healthy, fullterm infants.
   6. Must be on the market for at least one year before they will be considered for approval for the Missouri WIC.
7. The SA will use the procedures published in the invitation for bid to award the contract to the winning bidder.

2.3.100 Exempt Infant Formula and WIC-Eligible Nutritional Selection

Authority: 2019 7 CFR 246.10

Issued: 10/2002

Revised: 06/2020

Policy:

The state agency (SA) will evaluate all exempt infant formulas and WIC-eligible nutritionals on a product-by-product basis in accordance with the selection criteria to determine approval for issuance in the Missouri WIC program.

Procedure:

1. The SA shall collect information on exempt infant formulas and shall evaluate them based on the following:
   1. All exempt infant formulas must meet the requirements below:
      1. Must be approved by the U.S. Food and Drug Administration (FDA) and meet the definition and requirements for an exempt infant formula under section 412(h) of the Federal Food, Drug, and Cosmetic Act as amended (21 U.S.C. 350a(h)) and the regulations at 21 CFR parts 106 and 107 and be designed for enteral digestion via oral or tube feeding.
      2. Must be concentrated liquid, ready-to-feed (RTF), or reconstituted powders which are fed to infants and children with special dietary needs due to conditions including, but not limited to, premature birth, low birth weight, metabolic disorders, inborn errors of amino acid metabolism, gastrointestinal disorders, malabsorption syndromes, and severe food allergies. These products serve as substitutes for human milk.
      3. Must not require the addition of any ingredients other than water prior to being served in a liquid state.
      4. Must be determined WIC-eligible by USDA. Federal Regulatory requirements for WIC eligibility can be found here: Information for Food Manufacturers.
2. The SA shall collect information on WIC-eligible nutritionals and shall evaluate them based on the following:
   1. All WIC-eligible nutritionals must meet the requirements below:
      1. Specifically formulated to provide nutritional support for individuals with a qualifying condition, when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible nutritionals must serve the purpose of a food, meal or diet (may be nutritionally complete or incomplete) and provide a source of calories and one or more nutrients; and be designed for enteral digestion via an oral or tube feeding; and may not be a conventional food, drug, flavoring, or enzyme.
      2. Must be prescribed by a physician for a child older than 12 months of age or a woman who has special nutrient needs in order to manage a disease or health condition, except for the sole purpose of managing body weight.
      3. Must be labeled for the dietary management of a medical disorder, disease, or condition.
      4. Must be labeled to be used under medical supervision.
3. Items not allowed include:
   1. Formulas used solely for the purpose of enhancing nutrient intake or managing body weight addressing picky eaters or used for a condition other than a qualifying condition (e.g., vitamin pills, weight control products).
   2. Medicines or drugs.
   3. Hyperalimentation feedings (nourishment administered through a vein).
   4. May not be a conventional food.
   5. Enzymes, herbs, or botanicals.
   6. Oral rehydration fluids or electrolyte solutions.
   7. Flavoring or thickening agents.
   8. Feeding utensils or devices (e.g., feeding tubes, bags, and pumps) designed to administer a WIC-eligible formula.
   9. Sports or breakfast drinks.
4. Product description and information related to the product must be reviewed thoroughly to ensure that the product is appropriate for the intended uses.
5. The WIC SA nutrition coordinator shall review the results of the product evaluation and submit recommendations to the SA WIC director for approval.
6. The SA will revise the formula reference sheet if the product is approved by the Missouri WIC program. Not all formulas meeting the requirements listed will be approved.
7. The SA WIC director will send an e-mail message to all local agencies announcing approval or non-approval of exempt infant formulas and WIC-eligible nutritionals.

2.3.110 Food Selection Criteria

Effective: 07/2025

Issued: 01/1991

Authority references: 2025 7 CFR 246.10(b)(1)(i); 246.10(b)(1)(iii); 246.10(e)(12); WIC Policy Memorandum #2015-3

Policy:

The state agency (SA) will establish and apply food selection criteria to assess products for inclusion in the Approved Product List (APL). The SA must ensure that all approved products comply with the United States Department of Agriculture (USDA) regulatory requirements for WIC-eligible foods and take into account their availability in authorized retailers at the time of submission.

The SA reserves the right to modify the APL at any time due to changes in funding and appropriations, or to address product confusion that may arise from manufacturing labeling and production.

The table below shows which products can be evaluated for addition to the APL on a continuous basis and those only evaluated during limited submission periods.

Procedures:

1. The table below combines the SA food selection criteria and USDA regulatory requirements, presenting all criteria used to evaluate each category of WICeligible foods.

¹Beginning in April 2027, all approved yogurt must contain at least 106 IU of vitamin D per 8-oz serving.

²Added sugars include but are not limited to the following: corn syrup, dextrose, high-fructose corn syrup, honey, maltose, maple syrup and sucrose.

2.3.120 Food Package: State and LA Responsibility

Authority: CFR 246.10(b)(1)(2)(i)(ii)(iii)

Issued: 01/1981

Revised: 12/2016

Policy:

The state agency (SA) shall determine the foods which are acceptable for use in the Missouri WIC Program in accordance with the federal regulations. The competent professional authority (CPA) shall issue the WIC approved foods in accordance with state policy.

Procedures:

1. The SA:
   1. Identifies foods which are acceptable for use in the Missouri WIC Program.
   2. Provides a list of acceptable foods and maximum monthly quantities to local agencies, state auditors, and department auditors.
   3. Ensures all vendors maintain contractual minimum stock requirements.
   4. Monitors the local agency (LA) to assure that they meet their responsibilities for food issuance.
2. The LA:
   1. CPAs shall prescribe supplemental foods, formulas and WIC eligible medical nutritionals in quantities necessary to meet the food issuance standards according to state policy.

2.3.130 Direct Shipment of Formula

Effective: 10/2024

Issued: 06/2020

Authority references: 2024 7 CFR 246.12(a)(b), 246.16(a)(1)

Policy:

The state agency (SA) shall distribute non-contract standard infant formula, exempt infant formula and WIC-eligible nutritionals directly to the requesting local agency (LA) if the formula is unavailable from an authorized WIC retailer or pharmacy. The SA will ship the formula from WIC-approved contract formula companies or SA inventory. LAs must maintain inventory control and store the formula according to the manufacturer's guidelines until it is issued to the participant.

Contract infant formulas for which the SA receives a rebate shall not be directly shipped to the LA.

Procedures:

1. Direct distribution approval process:
   1. The LA should verify that the formula is unavailable at a local authorized WIC retailer or pharmacy before sending a WIC-86 request to the DSWICFormula@health.mo.gov inbox.
   2. A nutritionist or competent professional authority (CPA) at the LA shall fill out a Request to Direct Ship Formula to Local Agency (LA) form (i.e., WIC-86) and email it to DSWICFormula@health.mo.gov.
      1. The LA shall use a secure email address to submit the WIC-86 via an encrypted email, ensuring participant confidentiality.
         1. The LA shall not put any personally identifiable information (PII) of the participant in the email's subject line.
      2. LAs should allow at least 7-10 business days to receive the formula after the SA processes the request.
      3. LAs shall complete a new WIC-86 each month.
   3. The SA nutritionist on formula duty shall monitor the inbox and process all incoming requests. The SA nutritionist shall verify that the formula is unavailable through a local authorized WIC retailer or pharmacy.
   4. The SA nutritionist will send the form to the support staff responsible for ordering through a contracted formula company. Each direct ship request shall be reviewed and approved by the SA on a case-by-case basis. Refer to section N of the Formula Reference Guide: Criteria for SA Approval of Direct Shipments.
   5. The formula company will directly ship the formula to the LA. The SA shall send confirmation information for the order via an encrypted email, including a reference number, to the LA for monitoring formula delivery.
      1. If the LA does not receive confirmation information within three business days (not counting state holidays) of submitting their WIC86 to the DSWICFormula@health.mo.gov inbox, they should inquire about the status of their request. LAs may email the DSWICFormula@health.mo.gov inbox or call the WIC main phone line.
      2. Upon receipt of the formula, the LA shall attach all packing slips for the order to the confirmation email and forward them to DSWICFormula@health.mo.gov. Any information regarding the shipment, such as damaged or missing cans of formula, should be indicated in the body of the email.
         1. The LA shall take pictures of any damaged formula and attach them to their email to DSWICFormula@health.mo.gov. 
         2. The LA shall keep any damaged formula until SA responds with guidance.
2. Inventory and storage process:
   1. The LA shall keep an inventory of all formulas received by direct distribution using a tracking log. Documentation must include the participant’s state WIC identification (SWID) number, formula name, quantity, date received and staff initials.
      1. The LA will be billed for the cost of any formula that is unaccounted for or lost.
   2. Formula shall be stored in a cool, dry room out of participant view. Access to the formula should be limited.
   3. Formula shall be issued on a first-in, first-out basis and according to expiration date.
3. Issuance process:
   1. Once the formula is received, the LA will contact the participant and schedule a time for issuance and pickup. Future benefits shall not be issued. Direct shipment formula shall not be issued before the first day of the benefit month (e.g., formula ordered for Nov. benefits should not be issued before Nov. 1).
   2. Issuance shall be documented in the Management Information System (MIS) using the Direct Ship checkbox.
      1. If formula benefits were previously issued to the WIC card, the LA shall ensure that the formula is not over-issued using proper procedures. For maximum monthly allowances, refer to the Formula Reference Guide and the WIC Help Desk or Training Sessions webpage for guidance using the Food Adjustment Wizard.
   3. Once removed from inventory, the LA shall indicate issuance on a tracking log. The SA provides the WIC Formula Tracking Log on the Forms, Policies and Procedures page of the LA Portal; however, LAs may choose to use any log that tracks all of the required information found above in B.1.
4. Direct ship formula shall be issued to the participant for whom it was initially ordered. Extra formula due to a direct shipment should not be donated but must be retained in inventory for the intended participant until the following month’s issuance.
   1. If the participant no longer needs the direct-shipped formula, it may be issued to someone else at the LA or sent to another LA, as long as it never left the LA (i.e., returned formula). Refer to policy 2.3.080 for guidance on all returned formulas.
      1. The LA shall complete the Extra Direct Ship Formula (WIC-90) form and email it to the DSWICFormula@health.mo.gov inbox.

2.4.010 Training Local Agency Staff

Effective: 10/2025

Issued: 01/1981

Authority references: 2024 7 CFR 246.11; RSMo Section 324.200 to 324.225 and 335.011 to 335.420

Policy:

All contracted local agency (LA) staff who provide WIC benefits to eligible participants must complete the required training within the specified time frames. The LA must maintain documentation of completed training for all LA staff. The state agency (SA) will develop, maintain and provide training to LA staff on topics related to nutrition, breastfeeding, the Management Information System (MIS), civil rights, immunizations and voter registration.

Procedures:

1. The SA will provide LAs with training opportunities and resources for required training. Schedules and registration forms for all training can be accessed through the LA Portal. The LA is responsible for providing opportunities and resources for training new and returning employees.
   1. The LA will ensure that new and returning staff receive all required training according to their job responsibilities. See the All WIC Staff Training Chart for required training based on role. LA staff must complete webinars, modules, exercises and live sessions as needed to meet training requirements.
   2. LA staff who perform hemoglobin/hematocrit screenings must be trained on the correct procedures by HemoCue or an SA nutritionist prior to performing the screening.
   3. Staff returning to work after a break in service of one year or greater shall be required to complete the same training requirements as a new employee.
2. The SA requires LA staff to complete the following continuing education units (CEU) annually.
   1. All staff shall have at least one breastfeeding-related CEU. Staff must complete a different training each year.
   2. All professional staff must complete at least five additional nutrition or breastfeeding-related CEUs for a minimum total of six each year.
3. The LA shall maintain a current WIC Staff Training Record that lists training attended by LA staff for monitoring purposes.
   1. The LA must retain proof of the following active credentials of its professional staff (CPAs and nutritionists). Refer to policies 2.4.030 and 2.4.050.
      1. Registered dietitians (RD).
      2. Registered dietetic technician (DTR).
      3. Licensed dietitian (LD).
      4. Licensed practical nurse (LPN).
      5. Registered nurse (RN).
      6. International board certified lactation consultant (IBCLC).
   2. RNs, LPNs and nutritionists must retain documentation of completed CEUs on file at the LA.
      1. RDs, DTRs and IBCLCs are not required to report CEUs on the LA training record.

2.4.020 State Agency Responsibility: Nutrition Education

Authority: CFR 246.11(a)(b)(c)

Issued: 01/1981

Revised: 07/2009

Policy:

The state agency shall assure that appropriate nutrition education shall be made available to all participants at no cost.

Procedures:

1. Develop and coordinate the nutrition education component with consideration of local WIC provider plans, needs and available nutrition education resources.
2. Provide in-service training and technical assistance for local WIC provider staff involved in providing nutrition education to participants.
3. Identify or develop resources and educational materials for use, taking into consideration the need for resources in languages other than English.
4. Develop and implement procedures to ensure that nutrition education is offered to all adult participants and to parents or guardians of infant or child participants, as well as child participants whenever possible.
5. Assure an evaluation is conducted annually of nutrition education activities as perceived by the local WIC provider.
6. Monitor local WIC provider activities to assure nutrition education is provided as required.
7. Establish procedures to ensure participant contacts for nutrition education is provided and documented.

2.4.030 Local Agency Nutrition Personnel: Nutritionist

Effective: 10/2025

Issued: 01/1981

Authority references: 2024 7 CFR 246.11(d); 246.2; 246.4(a), 246.7(e)

Policy:

The nutritionist shall conduct nutrition assessments, assign risk factors and provide appropriate nutrition and breastfeeding education to all participants according to the state WIC program policies and procedures. The nutritionist may assist with the day-to-day supervision of any WIC staff, including a clerk, health professional assistant (HPA), competent professional authority (CPA) or nutritionist regarding program standard eligibility duties and activities. Successful completion of state-approved training must occur within the timeframes designated by the state agency (SA). Refer to policy 2.4.010.

Each local agency (LA) should staff nutritionists based on caseload at a minimum of one full-time equivalent (FTE) per 1,000 participants. Refer to section A.2.b of policy 2.4.040 LA Nutrition Personnel: Nutrition Coordinator.

Procedures:

1. The nutritionist is responsible for the following duties. The list below is not inclusive of all of the nutritionist’s responsibilities in the clinic.
   1. Obtains and documents demographic information, height/length, weight, hemoglobin and hematocrit, oral assessment, nutrition assessment and other necessary medical and/or health information to certify WIC participants. LA staff shall document all data obtained in the Management Information System (MIS). (Refer to the Health and Nutrition Assessment Handbook).
   2. Completes a nutrition assessment on the day of certification and mid-certification.
   3. Determines eligibility and assigns risk factors.
   4. Provides breastfeeding education and support to all participants which promotes breastfeeding as the preferred infant feeding method.
      1. Completes a breastfeeding assessment. When a mother requests formula supplementation, provide proper counseling, and if formula must be given, provide the minimum amount needed while offering counseling and support to help the mother establish a successful milk supply.
      2. May issue manual and electric breast pumps to breastfeeding participants per policy 2.1.030.
      3. May act as the breastfeeding coordinator (2.1.010) if assigned by the LA.
   5. Provides and documents all nutrition education and counseling, assistance with goal setting and follow-up about high-risk risk factors and topics.
   6. Prescribes appropriate food packages, exempt formulas and WIC-eligible nutritionals in accordance with policies and procedures.
   7. Coordinates nutrition services with medical providers as appropriate.
   8. Provides relevant health/nutrition information and referral services to participants.
   9. Participates in staff in-services and training sessions related to WIC policies and procedural changes.
   10. Participates in conducting studies and surveys.
   11. Provides recommendations for improvement of nutrition education materials used in the WIC program.
   12. Conducts training as assigned by supervising staff.
2. The WIC staff shall adhere to policy 8.1.030 to ensure program integrity.
3. Required knowledge, skills and abilities
   1. Working knowledge of the principles and practices of nutrition and food, particularly in relation to health and disease.
   2. Knowledge of the benefits of breastfeeding and understanding of how to support the breastfeeding mother.
   3. Some knowledge of current developments in public health nutrition and their application to the local nutrition program.
   4. Some knowledge of social, cultural and economic problems and their impact on public health nutrition.
   5. Skill in planning and organizing work assignments.
   6. Effective use of educational materials when providing nutrition education and counseling.
   7. Ability to gather, interpret, evaluate and use statistical data.
   8. Ability to present ideas clearly and concisely, orally and in writing.
   9. Demonstration of rapport building by establishing and maintaining effective working relationships with WIC participants, WIC team members and other health and social services personnel.
   10. A courteous and respectful attitude toward all participants in the WIC program.
   11. Skill in basic computer fundamentals and literacy.
   12. Some knowledge of adult learning principles, stages of change and basic counseling methods.
4. Minimum qualifications/education
   1. Must meet one of the following education qualifications a through d below:
      1. Graduation from an accredited college or university with a bachelor's or master’s degree in the field of nutrition. The degree must include or be supplemented by at least 15 semester hours in food and nutrition with at least one course in nutrition counseling, nutrition education (theories and practice), nutrition in the life cycle and food science; or
      2. Completion of an undergraduate curriculum accredited or approved by the Academy of Nutrition and Dietetics-Accreditation Council for Education in Nutrition and Dietetics (ACEND) resulting in a verification statement from a didactic program in nutrition and dietetics; or
      3. Completion of a dietetic internship program accredited or approved by ACEND resulting in a verification statement; or
      4. Registered dietitian (RD), licensed dietitian (LD) in the state of Missouri (registration or current eligibility for registration by the Commission on Dietetic Registration [CDR]).
   2. Must also meet one of the following:
      1. Meets educational requirements as listed for nutritionists in USDA’s Code of Federal Regulations, 7 CFR 246.2 under Definitions for Competent Professional Authority (CPA); or
      2. Meets qualifications as indicated in USDA’s Nutrition Services Standards, Nutrition Services Staffing section, Standard 3 Staff Qualifications, Roles and Responsibilities.
   3. An LA nutritionist who has worked for the Missouri WIC program prior to 1996 and does not meet the qualifications but completed the diet therapy course and/or the community nutrition class (sponsored by the Missouri Department of Health in 1995 or 1996), will have been grandfathered in as a qualified nutritionist. Some LA nutritionists were not required to take the community nutrition class because it was determined at the time that their experience with WIC was considered the equivalent of the community nutrition coursework.
      1. As long as there is no break in employment, a WIC nutritionist may move from one LA to another. Any break in service disqualifies the person from the status of being grandfathered in as an LA nutritionist.
      2. A memo written by the district nutritionist and attached to the nutritionist’s transcript will indicate that the individual meets Missouri’s qualifications for a WIC nutritionist.
   4. The LA shall send transcripts to the SA technical assistance (TA) nutritionist for review to ensure the candidate meets minimum education qualifications before the LA makes a job offer.
5. Continuing nutrition education requirements
   1. Registered, licensed dietitians (RD/LD) must maintain active registration and Missouri licensing from a participating board for monitoring purposes.
   2. Dietetic technician, registered (DTR) with a bachelor’s degree must maintain an active registration from a participating board for monitoring purposes.
   3. Nutritionists (other than RDs and DTRs) must complete a minimum total of six nutrition or breastfeeding-related continuing education units (CEUs) annually. One CEU must be breastfeeding-related. Retain a copy of documentation of completion of these hours on file at the LA for monitoring purposes. Resources for acceptable/approved CEUs are:
      1. Training approved by the CDR, the credentialing agency for the Academy of Nutrition and Dietetics, as continuing professional education (CPE) for RDs.
      2. Nutrition and breastfeeding training that provides lactation continuing education recognition points (LCERPs) by the International Board of Lactation Consultant Examiners (IBLCE) for lactation consultants.
      3. Training provided by other sources that are approved by the LA’s assigned SA TA nutritionist prior to attending the session.
      4. College nutrition courses from an accredited university.
   4. It is highly recommended that a variety of nutrition education topics be completed each year.

2.4.040 Local Agency Nutrition Personnel: Nutrition Coordinator

Effective: 10/2025

Issued: 07/2009

Authority references: 2024 7 CFR 246.2; 246.4(a); 246.11(d)

Policy:

The nutrition coordinator is responsible for participating in developing and implementing WIC nutrition services. Work involves coordinating all nutrition and breastfeeding services provided to participants. Successful completion of state-approved training must occur within the time designated by the state agency (SA). Refer to policy 2.4.010.

Procedures:

1. The nutrition coordinator is responsible for the following duties. The list below is not inclusive of all the nutrition coordinator’s responsibilities in the clinic.
   1. Planning and implementation of the nutritional components of the local agency (LA).
   2. Coordinating direct nutrition services to participants, such as supervising nutrition services staff, overseeing food and formula prescriptions and coordinating with medical providers as appropriate.
      1. Ensures all professional staff meet the required competencies and are approved by the SA technical assistance (TA) nutritionist prior to providing nutrition services independently.
      2. Strives to meet minimum staffing recommendations for nutritionists based on LA caseload of one full-time equivalent (FTE) per 1,000 participants.
   3. Acquiring and maintaining accurate health assessment equipment (i.e., scales and measurement boards). Refer to the Health and Nutrition Assessment Handbook for minimum criteria and maintenance guidelines for weighing, measuring and blood work equipment.
   4. Reviewing and approving all nutrition education materials and lesson plans for group education according to established criteria. Materials provided by the Missouri Department of Health and Senior Services (DHSS) do not require LA review and approval.
      1. All Family Nutrition Education Program (FNEP) lesson plans must be approved by the SA nutrition monitoring coordinator.
      2. The LA nutrition coordinator must observe the FNEP educator prior to the delivery of group nutrition education sessions and shall ensure that only approved lesson plans are utilized.
   5. Planning and evaluating the nutrition and breastfeeding component using various health/nutrition data from the SA and the Centers for Disease Control and Prevention (CDC).
   6. Preparing reports, records and other data related to nutritional services.
   7. Coordinating nutrition services with other WIC program operations, local agencies and community organizations.
   8. Participating in staff in-services and training sessions related to WIC policies and procedural changes.
   9. Participating in local and state work groups to improve nutrition and program services.
   10. Conducting training sessions on topics required by the SA, including anthropometric and biochemical skills.
   11. Completing nutrition portions of the Local Agency Plan (LAP).
   12. Developing and completing nutrition corrective action plans (CAPs).
   13. Assuming breastfeeding coordinator responsibilities if assigned by the LA.
2. The WIC staff shall adhere to policy 8.1.030 to ensure program integrity.
3. Required knowledge, skills and abilities
   1. Knowledge of the principles and practices of nutrition and food, particularly in relation to health and disease.
   2. Knowledge of current developments in public health nutrition and their application to the local nutrition program.
   3. Knowledge of social, cultural and economic problems and their impact on public health nutrition.
   4. Skills in planning and organizing work assignments.
   5. Effective development and use of educational materials for nutrition education and counseling.
   6. Ability to gather, interpret, evaluate and use statistical data.
   7. Ability to present ideas clearly and concisely, orally and in writing.
   8. Demonstrate rapport building by establishing and maintaining effective working relationships with WIC participants, WIC team members and other health and social services personnel.
   9. Knowledge of adult learning principles, stages of change and basic counseling methods.
   10. Skill in basic computer fundamentals and literacy.
4. Minimum qualifications/education
   1. Must meet one of the following education qualifications a through d below:
      1. Graduation from an accredited college or university with a bachelor's or master’s degree in the field of nutrition. The degree must include or be supplemented by at least 15 semester hours in food and nutrition with at least one course in nutrition counseling, nutrition education (theories and practice), nutrition in the life cycle and food science; or
      2. Completion of an undergraduate curriculum accredited or approved by the Academy of Nutrition and Dietetics-Accreditation Council for Education in Nutrition and Dietetics (ACEND) resulting in a verification statement from a didactic program in nutrition and dietetics; or
      3. Completion of a dietetic internship program accredited or approved by ACEND resulting in a verification statement; or
      4. Registered dietitian (RD), licensed dietitian (LD) in the state of Missouri (registration or current eligibility for registration by the Commission on Dietetic Registration [CDR]).
   2. Must also meet one of the following:
      1. Meets educational requirements as listed for nutritionists in the United States Department of Agriculture’s (USDA) Code of Federal Regulations, 7 CFR 246.2 under Definitions for competent professional authority (CPA); or
      2. Meets qualifications as indicated in USDA’s Nutrition Services Standards, Nutrition Services Staffing section, Standard 3 Staff Qualifications, Roles and Responsibilities.
5. Continuing nutrition education requirements
   1. Dietitians (i.e., RD/LD) and dietetic technicians (i.e., DTR) must maintain active registration from a participating board for monitoring purposes.
      1. Dietitians must also maintain an active Missouri license.
   2. Nutritionists (other than RDs/LDs and DTRs) must complete a minimum total of six nutrition or breastfeeding-related continuing education units (CEUs) annually. One CEU must be breastfeeding-related. Retain a copy of documentation of completion of these hours on file at the LA for monitoring purposes.
      1. Resources for acceptable/approved CEUs are:
         1. Training approved by the (CDR), the credentialing agency for the Academy of Nutrition and Dietetics, as continuing professional education (CPE) for RDs. 
         2. Nutrition and breastfeeding training that provides lactation continuing education recognition points (LCERPs) by the International Board of Lactation Consultant Examiners (IBLCE) for lactation consultants.
         3. Training provided by other sources that are approved by the LA’s assigned SA TA nutritionist prior to attending the session.
         4. College nutrition courses from an accredited university.
   3. It is highly recommended that a variety of nutrition education topics be completed each year.

2.4.050 Local Agency Nutrition Personnel: Competent Professional Authority

Effective:10/2025

Issued: 04/1995

Authority references: 2024 7 CFR 246.2; 246.4(a)(25); 246.6(b)(2)

Policy:

The competent professional authority (CPA) is responsible for obtaining participant data needed for the certification process according to state policies and procedures. The CPA prescribes supplemental foods and formulas and provides nutrition and breastfeeding education. The CPA may assist with the day-to-day supervision of the health professional assistant (HPA) regarding program standard eligibility duties and activities. Successful completion of state agency (SA) approved training must occur within the time designated by the SA. Refer to policy 2.4.010.

Procedures:

1. The CPA is allowed to perform the following duties (any one position may not include all of the duties listed):
   1. Obtains and documents demographic information, height/length, weight, hemoglobin and hematocrit, oral assessment, nutrition assessment and other necessary medical and/or health information to certify WIC participants. Local agency (LA) staff shall document all data obtained in the Management Information System (MIS). (Refer to the Health and Nutrition Assessment Handbook.)
   2. Completes a nutrition assessment on the day of certification for all participants.
      1. Identifies high-risk participants and schedules them to see the nutritionist. The CPA shall assign the participant a monthly issuance cycle and complete a SOAP note.
   3. Assists in the promotion and support of breastfeeding as the preferred method of feeding.
      1. Completes a breastfeeding assessment. When a mother requests formula supplementation, provide appropriate counseling. If a formula is necessary, offer the minimum amount needed while continuing to support the mother in establishing a successful milk supply.
      2. May issue manual or electric breast pumps to breastfeeding participants per policy 2.1.030.
      3. May act as the breastfeeding coordinator (2.1.010) if assigned by the LA.
   4. Determines eligibility and assigns risk factors.
   5. Provides nutrition education and counseling about non-high-risk risk factors and topics.
   6. Prescribes appropriate food packages, exempt formulas and WIC-eligible nutritionals in accordance with policies and procedures.
   7. Coordinates nutrition services with medical providers as appropriate.
   8. Provides relevant health/nutrition information and referral services to participants.
   9. Participates in staff in-services and training sessions related to WIC policies and procedural changes.
   10. May conduct training as assigned by supervising staff.
2. The WIC staff shall adhere to policy 8.1.030 to ensure program integrity.
3. Required knowledge, skills and abilities.
   1. Skill in accurately obtaining and analyzing anthropometric measurements and nutrition assessment of participants.
   2. Skill in planning and organizing work assignments.
   3. Demonstration of rapport-building skills by establishing and maintaining effective working relations with WIC participants, WIC team members and other health and social services personnel.
   4. Some knowledge of the principles and practices of nutrition and food, particularly in relation to health and disease.
   5. Knowledge of the benefits of breastfeeding and understanding of how to support the breastfeeding mother.
   6. Some knowledge of adult learning principles, stages of change and basic counseling methods.
   7. Some knowledge of social, cultural and economic problems and their impact on public health concerns.
   8. Some knowledge of the general organization and function of public health agencies.
   9. Effective use of educational materials when providing nutrition education and counseling.
   10. Skill in basic computer fundamentals and literacy.
4. Minimum qualifications. Applicants must fully meet one of the qualifications under sections 1 or 2 below.
   1. Education, certifications and registrations
      1. Registered nurse (RN), physician or physician’s assistant, dietetic technician, registered (DTR) with an associate degree; or
      2. Licensed practical nurse (LPN), International Board Certified Lactation Consultant (IBCLC); or
      3. A four-year degree in any field with a minor in nutrition from an accredited college or university; or
      4. A four-year degree in social work, sociology, counseling, psychology, public health, health education, health science, biomedical science or education from an accredited college or university.
         1. A four-year degree in a related field may be considered for approval by your SA technical assistance (TA) nutritionist. A transcript must be provided.
         2. Undergraduate nutrition hours are preferred but not required.
   2. Experience.
      1. Four years of consecutive WIC experience within the last six years as an HPA or breastfeeding peer counselor (BFPC).
         1. This substitution requires a Paraprofessional Recommendation form (i.e., the WIC-93) from the hiring LA nutrition coordinator and approval from the SA TA nutritionist.
5. Continuing nutrition education requirements:
   1. When required by state law, CPAs must maintain an active Missouri license for any credential that qualifies them as CPAs. See section D.1 above for all CPA qualifications.
   2. The CPA must complete a minimum total of six nutrition or breastfeedingrelated continuing education units (CEUs) annually. One CEU must be breastfeeding-related. Retain a copy of documentation of completion of these hours on file at the LA for monitoring purposes. Resources for acceptable/approved CEUs are:
      1. Training approved by the Commission on Dietetic Registration (CDR), the credentialing agency for the Academy of Nutrition and Dietetics, as continuing professional education (CPE) for RDs.
      2. Nutrition and breastfeeding training that provides lactation continuing education recognition points (LCERPs) by the International Board of Lactation Consultant Examiners (IBLCE) for lactation consultants.
      3. Training provided by other sources that are approved by the LA’s assigned SA TA nutritionist prior to attending the session.
      4. College nutrition courses from an accredited university.
   3. It is highly recommended that a variety of education topics be completed each year.

2.4.070 Local Agency Personnel: Health Professional Assistant

Effective: 10/2025

Issued: 11/1988

Authority references: 2025 7 CFR 246

Policy:

The health professional assistant (HPA) is a paraprofessional under the technical supervision of the competent professional authority (CPA) or nutritionist (i.e., professional staff) who assists in obtaining and entering the data for the certification process in the Management Information System (MIS). State-approved training must be completed within the timeframes designated by the state agency (SA). Refer to policy 2.4.010.

Procedures:

1. HPAs may assist professional staff in certifying participants by:
   1. Obtaining demographics, height or length, weight, blood work and immunization data.
   2. Entering certification data on the appropriate screens in the MIS.
   3. Promoting breastfeeding as the preferred feeding method.
   4. Referring participants to appropriate social, health and nutrition services.
   5. Providing all components of the program explanation per policy 8.1.080.
   6. Issuing food instruments and food benefits.
   7. Scheduling participants for group education and individual counseling.
   8. Participating in community outreach efforts as assigned by the CPA.
   9. Participating in staff in-services and training sessions related to WIC policy and procedural changes.
2. HPAs cannot:
   1. Complete the following screens in the MIS:
      1. Health Information.
      2. Risk Factors/High-Risk.
      3. Food Prescription.
      4. SOAP (Subjective, Objective, Assessment and Plan) Notes, including the nutrition and breastfeeding assessment.
      5. CPA Determined Follow-Up.
   2. Assign risk factors manually.
   3. Determine or extend the cycle for follow-up.
   4. Provide nutrition education and counseling.
   5. Prescribe and tailor food packages.
   6. Function independently of a CPA or nutritionist.
   7. Supervise any other positions.
3. The WIC staff shall adhere to policy 8.1.030 to ensure program integrity.
4. Required knowledge, skills and abilities.
   1. Obtain anthropometrics and blood work.
   2. Record medical and health data in the participant's file.
   3. Plan and organize work assignments.
   4. Build rapport with participants, team members and other health and social services personnel by establishing and maintaining working relations.
   5. Demonstrate an understanding of the benefits of breastfeeding and how to support the breastfeeding mother.
   6. Demonstrate basic computer skills and literacy.
5. Minimum qualifications.
   1. High school diploma or equivalency (i.e., GED/HiSET).
6. Ideal qualifications.
   1. Some credits earned in a nutrition-related allied health program.
   2. Two years of experience in a community health nutrition program.

2.4.090 Serving Homeless Persons

Authority: 2008 CFR 246.4(a)(6); 246.7(n)(1); 246.7(m); 246.12(o)

Issued: 05/1989

Revised: 07/2009

Policy:

The local agency (LA) shall ensure accessibility of WIC services to the homeless population. The LA may choose to not serve homeless persons who are institutionalized. If the LA provides WIC benefits to homeless or institutionalized individuals, the LA shall have a Memorandum of Understanding (MOU) between the LA and the homeless facility or institution.

Procedures:

1. The LA shall assure that:
   1. The potential participant resides within the specific geographic area in which LA operates one of the following options for the participant's address shall be used:
      1. The facility or institution address for the participant who frequently stays at one facility/institution.
      2. The address of a relative or friend.
      3. The address of the local WIC Program (especially for participants whose nighttime residence is a vehicle, park, sidewalk, etc.).
      4. A permanent address is not required for the application or certification process.
   2. The homeless person is eligible according to income guidelines and medical risks using usual assessment procedures.
   3. The applicant is referred to a health care provider (clinic, health center, physician if she/he has health insurance).
   4. The appropriate food package is issued based on availability of cooking facilities.
2. For the homeless person who resides in a homeless facility or institution (optional), the LA shall assure that:
   1. Only the individual WIC participant, for whom the supplemental foods were issued, and not the facility or any non-WIC or other WIC participant served by the facility/institution shall benefit from WIC.
   2. The facility/institution may not accrue financial or in-kind benefits from a homeless person's participation in WIC.
   3. Food items purchased with WIC food instruments shall not be used in communal feeding.
   4. No institutional constraints shall be placed on the ability of the WIC participant to receive or consume supplemental foods and all associated WIC services.
   5. Facilities/institutions not meeting these requirements will be notified that WIC participants cannot reside there.
   6. The participant is referred to complying facilities/institutions if the one where they reside is found to be out of compliance.
   7. Participants in facilities/institutions not meeting the required criteria will be eligible for only one certification period unless the facility/institution comes in to compliance with the criteria, or the participant moves to a compliant facility/institution.
   8. The conditions of compliance are not subjected to those facilities/institutions, which do not provide meals and offer no obstruction to full participation in WIC.
   9. Facility/institution will be requested to notify the LA if it ceases to meet any of the above conditions.
3. The LA shall have an MOU with the homeless or other institution where the WIC participant is residing.
   1. The MOU shall be developed and signed before the WIC participant begins residence in a homeless facility or other institution.
   2. The administrators or designees of the LA and the homeless facility or other institution shall sign the MOU.
   3. The MOU shall be kept on file at the LA and be available for the State WIC Office monitor.

2.4.100 Nutrition Education Materials

Effective: 05/2026

Issued: 01/1981

Authority references: 2025 CFR 246.11(c)(1)(3)

Policy:

The local agency (LA) nutrition and breastfeeding coordinators must review and approve all materials used for participant nutrition and breastfeeding education that have not already been approved by the state agency (SA), including group lesson plans and resource materials, to ensure they promote current, evidence-based nutrition and feeding practices appropriate for WIC participants.

The LA breastfeeding coordinator must review and approve materials specifically related to breastfeeding, while the LA nutrition coordinator must review and approve all other materials.

All outsourced or self-developed printed and electronic materials must be reviewed and approved by the appropriate LA coordinator at least every two years using the Nutrition Education Material Review form (i.e., the WIC-91). For self-developed group lesson plans, LA coordinators must use the LA Group Nutrition Education Lesson Plan form (i.e., the WIC-94).

All self-developed materials must include the Missouri WIC logo and the short nondiscrimination statement. Refer to policies 7.1.010 and 11.1.020.

Procedures:

1. All materials from the following sources are approved by the SA and do not require LA review.
   1. The Missouri Department of Health and Senior Services (DHSS) literature list.
   2. The United States Department of Agriculture (USDA).
   3. The American Academy of Pediatrics (AAP).
   4. The Centers for Disease Control and Prevention (CDC).
   5. Wichealth.org.
2. All other outsourced or self-developed materials may be approved if reviewed by the appropriate LA coordinator at least every two years.
   1. Complete the WIC-91 for approved resources.
   2. Complete the WIC-94 for approved self-developed group lesson plans. Refer to the instructions, which include a detailed lesson plan example and the corresponding WIC-94 provided by the SA.
   3. The LA coordinator may sign and date the original form to signify its review, revisions, if needed, and approval for another two years.
3. The LA must retain copies of all approved educational materials and their corresponding approval forms (i.e., WIC-91s and WIC-94s) for SA review during monitoring. The LA must organize all materials and forms together in an easily accessible format, either physical or electronic.
   1. The LA must retire or update any materials deemed inappropriate during SA monitoring.

2.4.110 General Nutrition Education

Effective: 10/2025

Issued: 10/2012

Authority references: 2025 7 CFR 246.11(e); MPSF: WC-06-17-P; ARPA Physical Presence Waiver 2023

Policy:

General nutrition education (i.e., nutrition education) is a WIC benefit. The local agency (LA) must make nutrition education, including breastfeeding promotion and support, available at no cost to all adult participants, authorized or alternate representatives and whenever possible and appropriate to child participants.

Nutrition education is tailored based on the nutrition assessment. It should emphasize the relationships between proper nutrition and good health, assisting the participant in achieving a positive change in food habits to meet their nutrition and health goals.

Nutrition education must be designed to be easily understood by the participants, adapted to meet different cultural, socioeconomic and language needs, incorporate the six elements of effective nutrition education and engage the participant. Refer to the USDA Nutrition Education Guidance.

Alternate representatives are expected to participate in nutrition education activities when the authorized representative is unable to participate.

Follow-up is required after all nutrition education for the competent professional authority (CPA) or nutritionist (i.e., professional staff) to provide ongoing support to the participant by reinforcing nutrition education messages, goals and referrals.

Procedures:

1. Nutrition education must:
   1. Be provided by appropriate professional staff. Refer to policy 2.3.050 and 2.4.030.

   2. Be offered at the following frequency:

      Months of certification	Nutrition education contacts
      10-12	4
      7-9	3
      4-6	2
      Up to 3	1

      1. All participants who miss or refuse nutrition education must be placed on a monthly benefit cycle until their education contacts are met. Refer to policy 1.1.020.
         1. LA staff must document all no-show or refused nutrition education by adding an individual or group nutrition education contact in the Management Information System (MIS) and selecting the appropriate No Show or Refused radio button.
   3. Take place on the same day the nutrition assessment is completed.
   4. Include the benefits of exclusive breastfeeding for all prenatal women at certification.
   5. Include substance use information provided to all authorized or alternate representatives at each certification and on an as-needed basis at subsequent visits.
   6. Include Next Steps for Health counseling to all women (prenatal, postpartum and breastfeeding) by the end of their certification to reinforce the importance of nutrition and health messages received through WIC. Refer to policy 8.1.100.
   7. Be based on any identified concerns of the participant and relate to the participant’s risk factors, areas of dietary deficiencies and other areas of nutritional concern.
      1. A maximum of two education topics per contact is recommended.
      2. If more than one family member is enrolled in WIC, prioritize nutrition education topics using critical thinking skills and professional judgment combined with the participant’s expressed needs and concerns.
   8. Include goal setting and follow-up after each nutrition assessment.
      1. Goals may relate to the participant’s risk factors, dietary habits or health and dental care.
         1. Goals cannot be set without the participant’s input; however, professional staff may guide the goal-setting process.
         2. The Specific, Measurable, Attainable, Realistic and Timebound (SMART) Acronym resource may guide the discussion and create a well-phrased, participant-centered goal.
      2. Follow-up must be completed before the certification end date determined by the MIS.
         1. Follow-up only counts as subsequent nutrition education if additional topics are covered.
   9. Be documented according to the following guidelines.
      1. Completed nutrition education topics must be documented in the MIS under the Nutrition Education tab. Documentation should be done by the staff who provided the education.
         1. The nutritionist must document high-risk nutrition education by selecting the High-Risk contact and the topic discussed from the MIS drop-down list.
         2. Substance use information must be documented as Alcohol/Substance Use under the Nutrition Education tab in the MIS.
      2. A general or Subjective, Objective, Assessment and Plan (SOAP) note must include the following components. Refer to the Missouri WIC Documentation Guidelines for Professional Staff for more guidance regarding SOAP note documentation.
         1. The participant’s understanding of the nutrition education.
         2. Any participant questions and how they were addressed.
         3. Nutrition education materials provided.
         4. A SMART goal.
      3. Follow-up documentation must include the current status of the participant’s goal.
         1. High-risk follow-up must be done by the nutritionist and documented in a SOAP note.
2. Nutrition education may be provided while the participant is either in person or remote. If requested by the participant, they must be allowed to do nutrition education in person at the clinic.
   1. At initial certification, nutrition education must be provided while the participant is in person at the clinic unless an exception from policy 8.1.060 applies. At the discretion of professional staff, all subsequent nutrition education and follow-up may be offered while the participant is remote or in person.
      1. The nutritionist must determine if remote nutrition education is appropriate for high-risk participants.
      2. Professional staff with advanced lactation training (i.e., the WIC breastfeeding (BF) curriculum levels 1-4, a Lactation Education Accreditation and Approval Review Committee (LEAARC) recognized 45-hour lactation course or is an IBCLC) must determine if remote nutrition education is appropriate for breastfeeding participants.
   2. The LA must document the method of remote nutrition education utilized by selecting Email Counseling, Telephone Counseling or Web-Based Nutrition Education in addition to the topic discussed under the Nutrition Education tab in the MIS.
   3. LA staff must provide remote nutrition education per policy 8.1.010 Participant Confidentiality.
   4. The LA must have a secure video platform available to offer participants who receive remote nutrition education. Video is not required for participants unless they choose to use it.
3. The professional staff is responsible for selecting appropriate nutrition education and materials. The nutritionist must determine appropriate nutrition education and materials for high-risk factors and topics.
   1. The LA nutrition or breastfeeding coordinator must review and approve all nutrition education and materials at least every two years if not already approved by the state agency (SA). Refer to policy 2.4.100.
   2. Self-paced lessons (e.g., wichealth) cannot be used at certification or midcertification assessment (MCA) but may be appropriate for subsequent nutrition education.
      1. Participants cannot repeat a self-paced lesson in the same certification period.
      2. Participants must provide documentation, electronically or hard copy (e.g., certificate or answer sheet), to verify completion.
      3. All LAs must have at least one staff member with an active wichealth staff account to verify and document completed wichealth lessons in the MIS.
         1. A clerk or health professional assistant (HPA) under the direction of professional staff, or professional staff themselves, must enter lessons completed through wichealth as Web-Based Nutrition Education and document the specific lesson title completed in a general or SOAP note.
         2. If a lesson topic applies to multiple household members based on their nutrition assessments, the education must be documented in each chart.
   3. Materials (e.g., handouts, pamphlets, newsletters, public service announcements, TV advertisements and take-home activities) may be provided in person or remotely to reinforce nutrition education messages provided by the professional staff, but cannot be used independently.
4. Group nutrition education is intended for two or more participants and may use activities that include, but are not limited to, demonstrations, physical activity or facilitated group discussions. Classes where fewer than two participants attend may still be counted as a contact. At the discretion of professional staff, group education may be appropriate for all participants as a subsequent nutrition education contact.
   1. Group nutrition education must follow an approved lesson plan to count as a nutrition education contact. Refer to policy 2.4.100.
   2. Group education provided by a Family Nutrition Education program (FNEP) educator must be observed by the nutrition coordinator before the class delivery.
      1. FNEP educators are not considered professional staff and cannot provide individual nutrition education to participants.
      2. All FNEP lesson plans require SA nutritionist approval.
      3. Professional staff must document all nutrition education provided by an FNEP educator by adding a group nutrition education contact in the MIS and selecting the FNEP topic. The specific lesson or topic must be included in a general note.
   3. Group education provided by the breastfeeding peer counselor (BFPC) will count as one of the nutrition education contacts for prenatal participants.
      1. The BFPC must document the nutrition education contact for the breastfeeding classes they teach in the MIS.
   4. Group classes may be offered remotely via a secure platform that allows for two-way communication.
      1. LAs should consider ways to adapt lesson plans for remote attendance.
      2. LAs must document classes as Web-Based Nutrition Education in addition to the topic discussed under the Nutrition Education tab in the MIS.